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TrainingFrontline StaffAssertiveCommunityTreatmentU.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESSubstance Abuse and Mental Health Services AdministrationCenter for Mental Health Serviceswww.samhsa.gov

TrainingFrontline StaffAssertiveCommunityTreatmentU.S. Department of Health and Human ServicesSubstance Abuse and Mental Health Services AdministrationCenter for Mental Health Services

AcknowledgmentsThis document was produced for the Substance Abuse and Mental Health Services Administration(SAMHSA) by the New Hampshire-Dartmouth Psychiatric Research Center under contract number280-00-8049 and Westat under contract number 270-03-6005, with SAMHSA, U.S. Departmentof Health and Human Services (HHS). Neal Brown, M.P.A., and Crystal Blyler, Ph.D., served asthe Government Project Officers.DisclaimerThe views, opinions, and content of this publication are those of the authors and contributors anddo not necessarily reflect the views, opinions, or policies of the Center for Mental Health Services(CMHS), SAMHSA, or HHS.Public Domain NoticeAll material appearing in this document is in the public domain and may be reproduced orcopied without permission from SAMHSA. Citation of the source is appreciated. However,this publication may not be reproduced or distributed for a fee without the specific, writtenauthorization from the Office of Communications, SAMHSA, HHS.Electronic Access and Copies of PublicationThis publication may be downloaded or ordered at www.samhsa.gov/shin. Or, please callSAMHSA’s Health Information Network at 1-877-SAMHSA-7 (1-877-726-4727) (Englishand Español).Recommended CitationSubstance Abuse and Mental Health Services Administration. Assertive Community Treatment:Training Frontline Staff. DHHS Pub. No. SMA-08-4344, Rockville, MD: Center for Mental HealthServices, Substance Abuse and Mental Health Services Administration, U.S. Department of Healthand Human Services, 2008.Originating OfficeCenter for Mental Health ServicesSubstance Abuse and Mental Health Services Administration1 Choke Cherry RoadRockville, MD 20857DHHS Publication No. SMA-08-4344Printed 2008

Training Frontline StaffThis workbook will help ACT leaders teach their ACT team membersabout the principles, processes, and skills necessary to delivereffective ACT services. It covers:n the basic elements of ACT,n the theory behind the ACT model,n the core processes that ACT teams follow, andn the types of services that ACT team members provide.Use this workbook as both a training manual for group sessionsand a basic desk reference.AssertiveCommunityTreatmentFor references see the booklet, The Evidence.

This KIT is part of a series of Evidence-Based Practices KITs createdby the Center for Mental Health Services, Substance Abuse andMental Health Services Administration, U.S. Department of Healthand Human Services.This booklet is part of the Assertive Community Treatment KIT thatincludes a DVD, CD-ROM, and seven booklets:How to Use the Evidence-Based Practices KITsGetting Started with Evidence-Based PracticesBuilding Your ProgramTraining Frontline StaffEvaluating Your ProgramThe EvidenceUsing Multimedia to Introduce Your EBP

What’s in this WorkbookHow Program Leaders ShouldUse This Workbook .........................APrepare program-specific information ................. BPrepare agency-specific information . . . . . . . . . . . . . . . . . . BVisit an existing team . . . . . . . . . . . . . . . . . . . . . . . . . . . . CArrange for didactic training . . . . . . . . . . . . . . . . . . . . . . . CRecruit a consultant .............................. CCross-train . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DFor more information . . . . . . . . . . . . . . . . . . . . . . . . . . . . DAssertiveCommunityTreatmentModule 1: Basic Elements of AssertiveCommunity Treatment .......................1How ACT began . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2How we know that ACT is effective . . . . . . . . . . . . . . . . . . . 2Active ingredients of ACT .......................... 3The ACT model vs. case management ................. 3ACT teams vs. other team approaches ................. 4Exercise: Explore the Benefits of ACT . . . . . . . . . . . . . . . . . . 9Exercise: Build an ACT Team . . . . . . . . . . . . . . . . . . . . . . . 11Exercise: Write a Mission Statement .................. 13

Module 2: Recovery and the StressvulnerabilityModel . . . . . . . . . . . . . . . . . . . . . . . . 1Recovery means more than just coping ................ 1Learn from other perspectives . . . . . . . . . . . . . . . . . . . . . . 3Think about recovery as a process .................... 3Convey hope ................................... 4Understand the Stress-vulnerability Model .............. 5Exercise: Practice What You’veLearned About Stressors ........................... 9Exercise: Practice What You’ve LearnedAbout Treatment Planning and theStress-vulnerability Model . . . . . . . . . . . . . . . . . . . . . . . . 25Module 3: Core Processes of AssertiveCommunity Treatment .......................1Here’s an overview of ACT processes .................. 2Engagement is a continuous process .................. 3Assessments are comprehensive,not isolated interrogations ......................... 4Learn about the comprehensiveassessment process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Use a Psychiatric/Social Functioning History Timeline ...... 8Create a treatment plan .......................... 10Make a Weekly Consumer Schedule . . . . . . . . . . . . . . . . . . 10Make a Daily Team Schedule . . . . . . . . . . . . . . . . . . . . . . . 12Conduct a daily team meeting ..................... 14Hold other team meetings ........................ 14Exercise: Case Studies Discussion — 1 ................. 15Exercise: Case Studies Discussion — 2 ................. 17Exercise: Compare Assessment Procedures . . . . . . . . . . . . . 19Exercise: Construct a Psychiatric/SocialFunctioning History Timeline ...................... 21Exercise: Prepare for Your Weekly Consumer Schedule ...... 25Exercise: Complete a Weekly Consumer Schedule . . . . . . . . . 29Module 4: Service Areas ofAssertive Community Treatment . . . . . . . . . . . . . . . . 1Treatment, habilitation, and support: An overview ........ 2Medication support .............................. 3Psychosocial treatment: A problem-orientedapproach to counseling/ psychotherapy ................ 4Community living skills . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Promote health ................................ 13Involve families ................................ 15Assist with housing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Employment .................................. 19

Training Frontline StaffHow Program Leaders Should UseThis WorkbookTraining Frontline Staff introduces ACTteam members to the basic principlesand skills they need to deliver effectiveAssertive Community Treatment(ACT) services. Use this workbook with theIntroductory Video (English and Spanishversions) and Practice DemonstrationVideo on the DVD in this KIT.Since being part of a team and learninghow to process information together is anessential part of ACT, we recommend thatyou conduct group sessions rather thansimply giving ACT team members theworkbook to read on their own. To makethe content easy to manage, we dividedthe training into four modules:1. Basic Elements of Assertive CommunityTreatment,2. Recovery and the Stress-vulnerabilityModel3. Core Processes of Assertive CommunityTreatment, and4. Service Areas of Assertive CommunityTreatment.The ultimate purpose of this workbookis to have staff begin to think and act likea team. A critical component of a wellfunctioningteam is open communication.Working through these modules as a groupcreates an opportunity to learn about howteam members communicate in a teamenvironment.Training Frontline StaffA

To complete this four-session training, you should:n Arrange for your ACT team members to meet once a week for 4 weeks. You will cover one moduleeach week.n In this workbook, on the page before each module, you’ll find Notes to the facilitator and program leader.Review them to prepare for the training in each module. The notes also include suggestions for additionalexercises you should consider to supplement the material in the module.n Copy and distribute the module’s reading materials to the team members before the session sothat they can read them beforehand. You’ll find each module on the KIT’s CD-ROM.n Copy the exercises for each module so that you can distribute them during eachsession. You’ll find them also on the CD-ROM.n For each session, ask a different team member to facilitate.n Begin each training session by showing the corresponding segment of thePractice Demonstration Video.n Discuss the information in the video and workbook.n Complete the suggested exercises for that module.Prepare program-specific informationIn addition to the materials in this workbook,prepare to give ACT team members informationabout ACT policies and procedures. Theseinclude the:n criteria for admitting people to the program,nlimited conditions under which people will bedischarged or “stepped down” to other services,nassessments team members will complete andthe timeframe for completing them,ncriteria upon which the program’s fidelity tothe ACT model will be assessed, andnoutcomes that will be monitored.Prepare agency-specific informationYou should also develop a plan to train members ofnew teams about other policies and procedures thatmay be relevant to the agency in which the teamoperates. These might include:nSafety: Many agencies with existing communitybasedprograms will have materials about safety.If training in this area is not already available,plan for training in de-escalation techniques. Youmight also seek a local law enforcement agencyto provide training in personal safety and crimeprevention strategies.nEmergencies: Team members must know theprocedures to follow if an emergency occurswhile they are in the community.nBilling procedures: Team members must knowhow to document their activities and bill forservices.nVehicles: Team members must understand thepolicies about using and maintaining vehicles.B Training Frontline Staff

nMandated reporting: Team members must knowhow to report suspected abuse and neglect.nConsumers’ rights: Team members should beaware of the State and Federal consumer rightsrequirements, especially the Americans withDisabilities Act.nOther policies and procedures: Consult youragency’s human resource office to learn of otherprogram, agency, or State policies that the staffshould know.Arrange for didactic trainingAfter using this workbook and visiting anexperienced team, you will be ready for atrainer who will help team members practicewhat they have seen and read. Some ACTleaders choose to hire an external trainer tointroduce ACT principles, processes, andskills. The initial training should take2 to 3 days.Visit an existing teamAfter your ACT team completes this workbook, wesuggest that new ACT team members observe anexperienced ACT team. Being familiar with thesematerials before visiting a team will make the visitmore productive. Rather than having to take timeto explain the basics, the host team will be able toshow the new ACT team members how to apply thebasics in a real-world setting.To find a team to visit in your area, contact:Assertive Community Treatment Association810 East Grand River Avenue, Suite 102Brighton, MI 48116(810) 227-1859www.actassociation.orgNational Alliance on Mental Illness2107 Wilson Boulevard, Suite 300Arlington, VA 22201-3042(800) 950-NAMIwww.nami.orgRecruit a consultantAfter the initial 2- to 3-day training, you, along withthe ACT psychiatrist, are responsible for ensuringthat the team follows the ACT model in their workwith consumers. This task can be challenging. Youmust facilitate a team development process, applywhat the team members have just learned aboutACT in their own clinical work with consumers,and, at the same time, ensure through clinicalsupervision that they follow the model.It is very easy to stray and do something similar to,but not quite the same as, ACT. Sometimes thishappens because teams believe they are diligentlyfollowing the ACT model, but they miss some ofthe more subtle aspects of it. In other cases, teamsstart well, but, as more consumers are admittedto the program and pressure mounts on the team,they revert to older, more familiar ways of working.To ensure that your team follows the ACT model,work with a consultant throughout the first yearof operation. A consultant can provide ongoingtelephone and in-person support to help you withyour challenging leadership role.If you need help finding a trainer or consultant,contact the Assertive Community TreatmentAssociation and the National Alliance on MentalIllness (mentioned above).Training Frontline StaffC

Cross-trainIt is important that staff throughout your agencydevelop a basic understanding of ACT. Crosstrainingwill ensure that other staff support thework that the ACT team undertakes. To help youmeet this need, we include these multimediamaterials in the ACT KIT:nthe introductory PowerPoint presentation,nsample brochure, andnthe Introductory Video.Once trained, ACT team members will be able touse these materials to conduct routine in-serviceseminars to ensure that all staff within the agencyare familiar with the ACT program.We also recommend that you use these materialsto train members of your ACT advisory group. Themore information that advisory group membershave about ACT, the better they will be able tosupport the team and its mission. Training is also anopportunity for team members and advisory groupmembers to become familiar with one another.Make sure that the advisory group members andteam members introduce themselves and that teammembers are familiar with one another’s roles.For more informationWe adapted much of the material in this workbookfrom A Manual for ACT Start-Up (Allness &Knoedler, 2003), published by the National Allianceon Mental Illness.This manual, written by Deborah Allness and BillKnoedler, is a valuable tool. Training Frontline Staffand other ACT KIT booklets complement but donot replace the manual.We consistently found that agencies used A Manualfor ACT Start-Up in conjunction with this KIT todevelop and manage their ACT programs. For thisreason, we recommend that you obtain a copy ofthe manual.Contact:National Alliance on Mental Illness(800) 950-NAMIwww.nami.org.D Training Frontline Staff

Notes to the facilitator and ACT leader:Prepare for Module 1:n Make copies of module 1, BasicElements of Assertive CommunityTreatment. Your copy is in thisworkbook; print copies for your teamfrom the CD-ROM.n Distribute the material to the team memberswho will participate in your group session. Askthem to read this module before meeting as agroup to discuss it.n Make copies of these exercises:o Explore the Benefits of ACTo Build an ACT Teamo Write a Mission Statementbut do not distribute them until your teammeets as a group. Again, your copies are on thenext pages; print copies for the team from theCD-ROM.Conduct your first session:n When you convene your group, viewthe Introduction and Basic Elementsof ACT on the Practice DemonstrationVideo. Discuss the video and the content ofmodule 1.n Facilitating the dialogue: Some peoplehave difficulty speaking in a group, perhapsbecause they are timid or soft-spoken. Othersmay feel professionally intimidated by thosewith more experience or higher degrees.Conversely, some team members will be selfconfidentand outspoken and will need to learnto listen openly to what others have to say.n Distribute your agency’s ACT admission anddischarge criteria to review and discuss.n One at a time, distribute the exercises tothe group and complete them. One ofthe roles of a facilitator and ACT leaderis to encourage people who are morewithdrawn to express their views and make sure thatmore vocal team members give others a chance tospeak. There will be an opportunity to assess theanxiety that team members may feel about workingon an ACT team.Consider this additional training activity:Identify communication styles:Many exercises identify differences in how peoplecommunicate and work. Often they involve a briefquiz or questionnaire that result in the personbeing identified as some particular “type” ofcommunicator or worker. If you do not have anexercise like this on hand, check with your HumanResources Officer. If you still cannot find an exerciseof this nature, the Myer-Briggs Type Indicator isused for this purpose but requires someone whois trained in interpreting it. Many adaptationsare available.The idea behind having your team membersdo an exercise of this nature is to help themunderstand their innate differences and to givethem a vocabulary for talking about thosedifferences. Ideally, the exercise should includetips on how people with different tendencies cancommunicate or work more effectively with other“types.” You can also use this as an icebreaker.Training Frontline StaffE

Training Frontline StaffModule 1: Basic Elements ofAssertive Community TreatmentModule 1 explains the basic elements of the ACT model, including the principlesof ACT, how ACT compares to case management as a service delivery system, howthe ACT team approach compares to other team approaches, and characteristicsof the population that receives ACT services. This module introduces cross-trainingby having team members begin to think about the professional knowledge andexpertise they have and how they could be valuable to other team members.Practice principles of ACTn ACT is a service-delivery model, not acase management program.n The primary goal of ACT is recoverythrough community treatment andhabilitation.n ACT is characterized by:o a team approach,o in vivo services,o a small caseload,o time unlimited services,o a shared caseload,o a flexible service delivery,o a fixed point of responsibility, ando 24/7 crisis availability.n ACT is for consumers with the mostchallenging and persistent problems.n Programs that adhere most closely to theACT model are more likely to get the bestoutcomes.Training Basic Elements Frontline of Staff ACT 1 Module 1

How ACT beganACT began when several mental healthprofessionals at the Mendota Mental HealthInstitute in Madison, Wisconsin, realized that manyconsumers were discharged from inpatient carein stable condition, only to return shortly after. Atbest, revolving door hospitalizations were acceptedas inevitable. At worst, consumers who did notfare well under the existing system of care werelabeled as noncompliant, treatment resistant, orunmotivated, and their needs went unmet.Rather than finding fault with the consumers whowere not benefiting from existing mental healthservices, the originators of ACT, Drs. ArnoldMarx, Leonard Stein, and Mary Ann Test, took adifferent approach. They looked at the way mentalhealth services were delivered and created a way tochange care so that people diagnosed with a seriousmental illness could become integral members ofthe community.n Problems with shifting skills into the communitywere exacerbated by the fact that manyconsumers diagnosed with a serious mentalillness were particularly vulnerable to the stressassociated with change and new experiences.The originators responded by designing a servicedeliverymodel in which a team of professionalsassumed responsibility for providing the specificmix of services that each consumer needed at theappropriate frequency, intensity, and length of time,and in which team members were available 24hours a day, 7 days a week.Services were provided in vivo— in the communityin places and situations where problemsarise, rather than in an office or clinic setting.Interventions were integrated through collaborationamong team members. The consumer’s responsewas carefully monitored so that the team couldquickly adjust interventions to meet changingneeds. Rather than brokering services from otherproviders, team members provided an array oftreatment and habilitation support themselves.What the originators foundn After discharge, the variety and intensity ofservices to support consumers in their livesoutside the hospital decreased dramatically.n Services, often clinic-based, differed by admissioncriteria, the types of services offered, anddischarge criteria.n Regardless of consumers’ needs, many programswere available only for a limited period and didnot follow up with discharged consumers.n Services were structured in a way that assumedconsumers progressed steadily from more- toless-structured services without consideringindividual differences in the course of recovery.n If a service was not available, no one wasresponsible for ensuring that consumers got thehelp they needed.n Even when a considerable amount of time wasspent in the hospital teaching consumers theskills they needed to live in the community, theseskills did not generalize to community living.How we know that ACT is effectiveSince the original ACT program began in Madison,Wisconsin, nearly 30 years ago, programs havebeen implemented in 35 States and in Canada,England, Sweden, Australia, and the Netherlands.As ACT spread, researchers carefully studied itseffectiveness. Reviews of ACT research consistentlyconclude that, compared with other treatments(e.g., brokered or clinical case managementprograms), ACT greatly reduces psychiatrichospitalization and leads to a higher level ofhousing stability (Phillips et al., 2001).Research also shows that, compared to othertreatments, ACT has the same or better effect onconsumers’ quality of life, symptoms, and socialfunctioning. In addition, consumers and familymembers report greater satisfaction (Bond et al.,2001; Phillips et al., 2001).Module 1 2 Training Basic Elements Frontline of Staff ACT

While studies consistently show that ACT isassociated with many beneficial outcomes, thePatient Outcomes Research Team (PORT) madeup of researchers from the University of Marylandand Johns Hopkins University found that peoplewho might benefit from ACT often do not receivethis intervention (Lehman et. al., 1998). Thosefindings ultimately led to creating this KIT. Formore information about the effectiveness of theACT model, see The Evidence in this KIT.Active ingredients of ACTOne of the unique features of ACT is that theimportant characteristics of this intervention havebeen delineated. The characteristics of ACT havebeen translated into program standards to helpmake certain that programs that want to replicateACT can.An instrument called the ACT Fidelity Scale isavailable to help teams assess how closely theirprogram follows the ACT model (See EvaluatingYour Program). Your ACT leader will distribute thisto you to review and discuss during this training.Some of the basic characteristics of ACT include:n Team approach: ACT team members with variousprofessional training and general life skills workclosely together to blend their knowledge andskills.n In vivo services: Services are delivered in theplaces and contexts where they are needed.n Small caseload: A team of 10 to 12 staff servesapproximately 100 consumers, resulting in a staffto-consumerratio of approximately 1 to 10.n Time unlimited services: A service is providedas long as needed, not according to pre-settimelines.n Shared caseload: ACT team members do nothave individual caseloads, rather the team as awhole is responsible for ensuring that consumersreceive the services they need to live in thecommunity and reach their personal goals.n Flexible service delivery: The team meets daily todiscuss how consumers are doing. The team canquickly adjust the services they are providing torespond to changes in consumers’ needs.n Fixed point of responsibility: Rather than sendingconsumers to various providers for services, theteam provides the services consumers need.If using another provider cannot be avoided(e.g., medical care), the team makes certain thatconsumers receive the services they need.n 24/7 crisis services: Services are available24 hours a day, 7 days a week. Team membersoften find, however, that they can anticipateand avoid crises.The ACT model vs. case managementACT is a model of care that provides treatmentand rehabilitation, as well as case managementservices. While case management has been definedas the coordination, integration, and allocation ofcare within limited resources (Bond et al., 2001),ACT is a more comprehensive service model.The typical goals of case management — preventinghospitalization, improving quality of life, improvingclient functioning — as well as some typicalcase management activities — service planning,assessment, and advocacy — overlap with thosefor ACT programs. However, the methods andresources to achieve these ends differ sharply.Unlike ACT, traditional case managers usuallybroker services, linking consumers to other serviceproviders, rather than intervening directly. Casemanagers usually have individual caseloads,unlike ACT teams with shared caseloads anda team approach. Unlike case managers, ACTteam members meet daily as a team and offercomprehensive services to consumers.Training Basic Elements Frontline of Staff ACT 3 Module 1

Table 1: Comparing Case Management and ACTCase Management ProgramsACT Service Delivery ModelCaseloads of 30 or more Staff-to-consumer ratio of about 1 to 10Services “brokered” from other providersAll services provided directly by team membersCase managers have sole responsibility for peopleassigned to themChange in intensity of services means change inprovidersConsumers receive services they need IF the serviceexists, the consumer meets eligibility criteria, and spaceexists in the programConsumers may be dropped from caseload if they arenoncompliant, in jail, or receiving services elsewhereIf a case manager quits or goes on vacation, consumersare switched to someone else or do not receive servicesTreatment plans are updated monthly or less oftenTeam members share responsibility for all consumersType and intensity of services can be varied easilyTeam members provide ANY service consumers needTeam is responsible for ensuring consumers receiveservices they need, even if they are difficult to engage,get arrested, or are hospitalizedIf a team member quits or goes on vacation, other teammembers who know the consumer continue service plansTeam discusses changes in consumers’ status daily andadjusts treatment, as needed(Bond et al.,2001)ACT teams vs. other team approachesACT uses transdisciplinary teamsAlthough on ACT teams, people from multipledisciplines work together, technically they are notmultidisciplinary teams. Rather, ACT teams aretransdisciplinary teams.Transdisciplinary teams blend the knowledge andskills of professionals from multiple disciplines.They transcend the typical provider-consumerrelationship by giving consumers a decisive voicein which services they receive and how theyreceive them.This model allows providers to deliver acomprehensive and integrated array of servicesto consumers who have complex needs.ACT teams are set up around a goal — keepingconsumers out of the hospital and supporting theirrecovery from mental illness. This is very differentfrom the way mental health services are usually setup. Typically, services are set up in a predeterminedhierarchy or configuration.In contrast, the configuration of ACT services is notpredetermined. Rather than trying to fit consumersinto a rigid service system, services fit consumers’goals and needs.See Table 2 on the next page for a comparisonof team models.Module 1 4 Training Basic Elements Frontline of Staff ACT

Table 2: Comparing Team ModelsMultidisciplinary Interdisciplinary TransdisciplinaryAssessmentSeparate assessments byteam membersSeparate assessments withconsultationTeam members conduct comprehensiveassessment togetherConsumerparticipationConsumers meetwith individual teammembersConsumers meetwith team or teamrepresentativeConsumers are active and participatingteam membersService plandevelopmentTeam members developseparate plans fordisciplinesTeam members shareseparate plans with oneanotherTeam members and consumers developplans togetherService planimplementationTeam membersimplement part of theplan related to theirdisciplineTeam members implementtheir section of the planand incorporate othersections where possibleThe team is jointly responsible forimplementing and monitoring the planLines ofcommunicationInformal linesPeriodic, case-specificteam meetingsRegular team meetings with ongoingtransfers of information, knowledge, andskills shared among team membersGuidingphilosophyTeam memberrecognizes theimportance ofcontributions fromother disciplinesTeam members are willingand able to develop,share, and be responsiblefor providing services thatare part of the totalservice planTeam members make a commitment toteach, learn, and work together acrossdisciplinary boundaries in all aspects toimplement unified service plansStaffdevelopmentIndependent withineach disciplineIndependent within, aswell as outside of, owndisciplineAn integral component of workingacross disciplines and team buildingSeveral things can go wrong in the more traditionalhierarchal system, especially when service usershave needs that are as complex as the needs ofconsumers receiving ACT services. In traditionalservice models, services may be deliveredsequentially. For instance, one provider at oneagency treats the consumer’s mental illness and,after that problem is treated, the consumer is sentto a substance abuse treatment program or to avocational program. One of the problems with this“pass around” approach is that many problemsare too pressing to wait for attention, and someproblems are of such a protracted nature that theconsumer might never see the next provider.Another problem under the typical care system isproviding parallel services. For instance, a mentalhealth professional and a substance abuse treatmentprovider work with consumers at the same time.Although these professionals may communicatewith one another, they may also duplicate effort,miss information that might be relevant to the otherprovider, or work at cross-purposes.In transdisciplinary teams, team members worktogether intimately so that each team member candraw on other team members’ knowledge, skills,and observations, and on a precise combination ofcarefully crafted, well-integrated services.Training Basic Elements Frontline of Staff ACT 5 Module 1

Communication and cross-training are keyOpen communication is essential to providingintegrated services. ACT teams work in sharedspace to facilitate sharing information informally.They meet daily to talk about each consumer.Since it is difficult to have transdisciplinary teams ifsome consumers are “yours” and some are “mine,”members of ACT teams do not have individualcaseloads. Specific consumers may be assignedto mini teams for administrative purposes, wherea subgroup of team members works closely withparticular consumers, but the team as a whole isresponsible for the success of every consumer.For transdisciplinary teams to function optimally,cross-training must occur. This does not mean thatevery member of the team must prescribe medicineor perform physical examinations; some tasks aregoverned by licensure and laws. However, manythings that team members know that are specific totheir discipline can be taught to people from otherdisciplines. Team members then become extra eyesand ears, can recognize when a problem is brewing,can help deliver or reinforce interventions, and cancommunicate from a broader perspective aboutwhat is happening with each consumer.Cross-training occurs during comprehensiveassessments, treatment planning, and dailymeetings. On new teams, cross-training canbe facilitated by having members of differentdisciplines work together with consumers. Byobserving the types of questions that teammembers from other specialties ask and by findingout why that information is important, colleaguescan begin to understand one another’s professionalperspectives and skills. Teams can also makeopportunities for members from various disciplinesto “teach” their team members about theirdiscipline.Working on a transdisciplinary team can betaxing, requiring flexibility and a willingness toset aside professional turf. But it can also be veryrewarding. Many professionals who have workedin this model find that it reduces stress becauseother team members are available for expertiseand support. They enjoy opportunities to learnfrom other disciplines. They also see that the workenvironment is enriched and problem-solving iseasier. Most of all, professionals find it rewardingto see consumers benefit from a service model thatmeets their needs and helps them achieve greaterindependence.How ACT teams relate to other servicesMany capable people in mental health and relatedsystems deliver quality care. However, someconsumers need a higher level of resources anda different approach to service delivery. This is afact, not a criticism of the work of individual mentalhealth professionals.Your ACT team may find that other professionalswithin the mental health system envy your team’sresources, training, and skills. You will need tobuild relationships with other providers to ensureseamless and coordinated care, for instance, ifhospitalization is unavoidable or if a consumerwho has been stable for an extended period mustbe “stepped down.” Team members must partnerwith professionals in other services to ensure thatconsumers receive proper and continuous care.Module 1 6 Training Basic Elements Frontline of Staff ACT

Who uses ACT servicesACT is designed for consumers who arecharacterized as those in the greatestneed — estimated to be 20% to 40% of people withserious mental illness. Criteria for selection includepsychiatric disorders (e.g., schizophrenia andbipolar illness), which severely impair functioningin the community. Impairment is likely in multipleareas:n inability to perform practical tasks required forbasic functioning in the community,n inability to be consistently employed or to carryout homemaker roles, orn inability to maintain a safe living situation.These consumers are also likely to have a historyof high-service needs, for instance, repeatedhospitalizations, a history of being involved withsubstance abuse or the criminal justice system,substandard housing, or homelessness. Someprograms focus exclusively on a single facet,for example, on a criminal justice or homelesspopulation, influencing the amount of specializedexpertise required by the full team.Consumers are not excluded from receivingservices because of severity of illness,disruptiveness in the community or in the hospital,or failure to participate in or respond to traditionalmental health services (e.g., outpatient therapy,day treatment). During acute episodes, consumersare often unable to adequately care for themselvesand need intensive services and supports, includinghospitalization. Symptoms may completely remitwith effective treatment for the majority ofconsumers, but for others, symptoms only partiallyremit and they experience them continuously.In addition to symptoms, a significant numberof consumers with severe psychiatric conditionshave persistent impairments that cause longtermdisability and poor community functioning.Impairment may be present months or years beforethe onset of recognizable psychiatric symptoms,may worsen during acute symptom episodes, andtend to persist even after symptom remission. Someimpairment requires a long-term, ongoing, andconsistent approach to intervention.Even more than symptoms, impairments produceenduring challenges in employment, personal care,and socialization making living in the communityoften difficult and, in some circumstances,impossible without extensive and regular assistancefrom others. Many consumers struggle with day-todayliving tasks, such as personal hygiene, cooking,shopping, and managing money. As a result ofthe impairments associated with serious mentalillnesses, consumers are often single and isolatedwith few non-family relationships and supports.Unemployment or ability to work only part-timeor intermittently is another significant issue.Compounding these difficulties are the stigma andrejection that consumers experience from the restof the community.As a consequence of problems in daily living,consumers are typically poor and financiallydependent on family and on entitlements and otherbenefits, such as Supplemental Security Income,Social Security Disability Insurance, Medicaid, orveterans’ benefits. Many consumers cannot afforddecent housing, making them a significant portionof the homeless population in the United States.Further, poverty along with mental illness makesconsumers more vulnerable to victimization and toarrest and incarceration, mostly for misdemeanoroffenses. Consumers also frequently becomeinvolved in using and abusing alcohol or othersubstances and they more often die prematurelyfrom suicide or physical illness.Training Basic Elements Frontline of Staff ACT 7 Module 1

About the consumers in greatest needACT programs serve consumers with the greatestneed — people who have severe symptoms andimpairments that are not effectively remedied byusual treatment or who, for reasons related to theirmental illness, resist, or avoid being involved withtraditional mental health services.Consumers in greatest need...n have major symptoms (such as experiencinghallucinations and delusions most hours ofthe day and, consequently, being fearful andisolated) that improve only partially or not atall with medication and other treatmentsn are seriously disabled from mental andbehavioral impairments (such as being evictedbecause they cared poorly for their residenceand disrupted neighbors, or losing jobsbecause of poor concentration and anxietyabout co-workers)n have co-existing substance use disorders,physical illnesses, or disabilities (such asdiabetes or visual impairments)n avoid being involved in services, do notacknowledge that they have a mental illness,and view mental health services as a threator as unnecessaryn have limited ability to meet the participationexpectations of standard psychiatric servicesdue to:o symptoms (i.e., they are disorganizedand confused),Because they do not wish for or cannot receiveconsistent help, many of these consumers gowithout services and persistently experiencesymptoms and impairment. They are at risk ofbecoming more refractory to treatment when theydo eventually receive it.Consumers in greatest need often have the poorestquality of life and result in the greatest costs tosociety of people with serious mental illnesses. Inparticular, these consumers are more likely to:n frequently use emergency and inpatient medicaland psychiatric services,n be homeless or live in substandard housing,n be arrested and incarcerated, orn die prematurely from suicide or physical illness.Many of these consumers may have already beenordered into treatment involuntarily (e.g., inpatientcommitment, probation, or parole expectations)and consequently approach their caregivers withanger and resentment. Providing effective servicesfor them requires providers to reach out and:n visit these consumers in the community, on thestreet, or in jails, shelters, and impoverishedliving situations;n understand substance use; andn listen, support, and provide assistance, even whenconsumers may have trouble following through(e.g., paying bills).o impairments (i.e., they are anxious,withdraw socially, and have limitedattention span), ando associated problems (i.e., substance useor sexual inappropriateness)n are diagnosed with serious mental illness andsometimes view such traditional programsas stigmatizing and limiting rather than aspromoting their opportunity to have normallife experiences (e.g., job, home)Module 1 8 Training Basic Elements Frontline of Staff ACT

Exercise: Explore the Benefits of ACTStudies that have explored what makes a difference in whether ACT team members adopt a new approach totreatment have found that ACT team members are more likely to adopt a practice if it addresses an area inwhich they feel they must improve. With ACT, it may not be so much a matter of whether an individual ACTteam member needs to improve, but of radically addressing how services are organized and delivered. Shareyour experiences where the traditional service delivery system has been inadequate and identify aspects ofACT that address those inadequacies.Some experiences where the traditional service delivery system has been inadequate:n nnnnnHow ACT may address those inadequacies:nnnnnTraining Basic Elements Frontline of Staff ACT 9 Module 1

Module 1 10 Training Basic Elements Frontline of Staff ACT

Exercise: Build an ACT TeamAnswer the following questions to help reinforce your understanding of ACT and how it might help theconsumers you work with.1. Before ACT, which characteristics of mental health services made it difficult for “consumers with thegreatest need” to get the services they needed? What were these problems?nnnn Have you ever encountered any of these problems when working with people diagnosed with a seriousmental illness? If so, what happened to these people?o o o o o n Which aspects of ACT might have made a difference? Explain.o o o o o Training Basic Elements Frontline of Staff ACT 11 Module 1

2. Why would it be inaccurate to describe ACT as just a case management program?3. What characteristics of ACT programs help to facilitate communication among team members?nnnn4. What are your agency’s ACT admission and discharge criteria?nnnn5. As you anticipate working on an ACT team, what do you expect to be the most difficult or challengingaspect of it?6. What do you expect to be the most satisfying aspect of working on an ACT team?Module 1 12 Training Basic Elements Frontline of Staff ACT

Exercise: Write a Mission StatementPart of being familiar with the ACT model and working as a team is being clear about goals. Develop a briefmission statement, a one-line motto, and a team logo.n Mission statementn One-line motton Team logoTraining Basic Elements Frontline of Staff ACT 13 Module 1

Module 1 14 Training Basic Elements Frontline of Staff ACT

Notes to the facilitator and ACT leader:Prepare for Module 2:n Make copies of module 2, Recoveryand the Stress-vulnerability Model. Yourcopy is in this workbook; print copiesfor your team from the CD-ROM.n Distribute the material to the team memberswho will participate in your group session. Askthem to read this module before meeting as agroup to discuss it.n Make copies of these exercises:o Practice What You’ve Learned AboutStressorso Practice What You’ve Learned AboutTreatment Planning and the Stress-vulnerabilityModelbut do not distribute them until your teammeets as a group. Again, your copies are on thenext pages; print copies for the team from theCD-ROM.Conduct your first session:n When you convene your group, view theRecovery and the Stress-vulnerabilityModel on the Practice DemonstrationVideo. Discuss the video and the contentof module 2.n One at a time, hand out the exercises to thegroup. Complete them.Consider these additional training activities:Panel discussion: To learn about consumers’and family members’ perspectives, set up a paneldiscussion. Invite 3-5 people who have receivedmental health services and those who have familymembers who have been diagnosed with a seriousmental illness. Include members of the team’sAdvisory Group, consumers, or people identifiedthrough local consumer or family groups.Ask panelists who have experienced mental illnessto be ready to discuss the effect of their illnessand to share any experiences with the mentalhealth system that were helpful and not helpful.Ask family members to discuss how they foundout their family member had a mental illness,how the illness has affected the family, and whatexperiences they have had with the mental healthsystem that were helpful and not helpful.Have panelists each speak and then ask them ifthey would answer questions from the team.Learn from the National EmpowermentCenter (NEC): NEC’s website has stories andarticles written by people who have experiencedpsychiatric disorders. The articles give you aglimpse of what it is like to receive mental healthservices and include accounts of personal journeysto recovery. You will find articles to share with yourteam, as well as training materials that can helpteam members better understand the experienceof mental illness. www.power2u.orgRead more about recovery: Much of theinformation on recovery in this module comesfrom a SAMHSA report called A Review of RecoveryLiterature by Dr. Ruth O. Ralph (2000). You candownload this report in its entirety (approximately30 pages) from the National Technical AssistanceCenter for State Mental Health Planning (NTAC)through the National Association for State MentalHealth Program Directors (NASMHPD) website atwww.nasmhpd.org/ntac/reports/ralphrecovweb.pdfTraining Basic Elements Frontline of Staff ACT 15 Module 1

Training Frontline StaffModule 2: Recovery and theStress-vulnerability ModelTwo concepts are essential to understanding the goals and objectives of ACT:n Recovery, especially in the context of serious mental illness, embraces a hopefulvision for people who experience psychiatric disorders. Since the ultimate goal ofACT services is to support the consumer’s recovery process, it is important to focuson this concept.n The Stress-vulnerability Model provides a useful framework for understandingmental illness and factors that influence its onset and course. The stressvulnerabilitymodel also offers a framework for thinking about the objectives ofthe services that ACT teams provide and skills that consumers need for recovery.Recovery means more thanjust copingThe idea of recovery from serious mentalillness may be new to you if you came ofage professionally in an earlier era whenthe mental health field generally heldlow expectations for people with seriousmental illness. Recovery embraces a morehopeful vision for people who experiencepsychiatric disorders.In a recovery framework, the expectation isthat people who experience serious mentalillness can live a life in which mental illnessis not the driving factor for their lives.Recovery means more than expectingpeople to simply “cope” with mental illnessor “maintaining” people with mentalillness in the community. In a recoveryframework, as a mental health practitioner,you are called on to be a source of hope,support, and education, and to partner withTraining Basic Recovery Elements Frontline and the of Staff Stress-vulnerability ACT Model 1 Module 12

consumers on their journey through mental illnessand the accompanying social consequences. Peoplewith mental illness are looking for:n support and education so they can takeresponsibility for controlling their symptoms;n encouragement to set personal goals and worktoward them; andn help getting facts, planning strategies, gatheringsupport, and targeting their efforts.A SAMHSA publication by Dr. Ruth Ralph,prepared for the National Technical AssistanceCenter for State Mental Health Planning (NTAC)and the National Association for State MentalHealth Program Directors (NASMHPD), describesrecovery as:“…a process in which consumers learn to approachdaily challenges, overcome disability, learn skills, liveindependently, and contribute to society” (Ralph,2000).Helping consumers in the process of recovery is theultimate goal of ACT teams.The dictionary talks about recovery in terms ofregaining something or getting something back. Inconsumers’ comments about recovery, they repeatthemes of regaining:n hope,n motivation,n self-confidence,n meaning, andn independence.Consequently, it is important for ACT teammembers to convey the belief that consumers can:n get well and stay well for long periods of time,n work toward and meet goals, andn lead happy and productive lives.Consumers who were involved in developing theACT KIT materials discussed the importance ofgoals in providing meaning and instilling hope. Asone consumer said:“I have to have goals. That’s what gives my lifemeaning. I’m looking to the future.”According to another consumer:“It’s about motivation.”For another consumer, the issue is self-esteem:“Recovery is about having confidence and self-esteem.There are things I’m good at, and I have somethingpositive to offer the world.”Independence is also important:“The most important thing in my recovery is to be asindependent as possible. I’m working at that all thetime.”ACT team members work with consumers to helpthem achieve maximum independence in manyareas including housing, finances, and medicationmanagement. Team members can also helpconsumers become more independent in theirrelationship with the mental health system byeducating them about mental illness and treatmentoptions and by relating to them as partners in thetreatment process rather than as the subjects oftreatment.For more information about the idea of motivationand how to use it in helping consumers withrecovery, see the Illness Management andRecovery KIT.Module 12 2 Recovery and the Stress-vulnerability Training Basic Elements Frontline of Model Staff ACT

Learn from other perspectivesWe are not suggesting that recovery means thatconsumers simply go back to where they werebefore the onset of illness. For one thing, we areall continuously changing, growing, and learning.Further, being diagnosed with a serious mentalillness is a life-altering experience. For thesereasons and others, some consumers prefer to talkabout the experience of mental illness in termsother than recovery.For a broader view of consumers’ thoughts aboutthe experience of mental illness, consider thesequotes:“I am not recovered. There is no repeating, regaining,restoring, recapturing, recuperating, retrieving. Therewas not a convalescence. I am not complete. WhatI am is changing and growing and integrating andlearning to be myself. What there is, is motion, lesspain, and a higher portion of time well-lived”(Caras, 1999).“Our lives seem not to follow a traditional linearpath; our lives appear to be like advancing spirals.We relapse and recuperate, we decide and rebuild,we awaken to life and recover/discover, and then wespiral again. This spiral journey is one of renewal andintegration, the dynamic nature of this process leadsto what can only be described as transformation.Recovery and rehabilitation imply that someone wasonce broken and then was fixed. Transformationimplies that proverbial making of lemonade afterlife hands you lemons. It is the lesson, hard learned,of the opportunity available in the midst of crisisthat evokes a substantive change within ourselves”(Cohan & Caras, 1998).Think about recovery as a processRecovery does not mean the same thing as cure.When we use the term recovery in this book, wedo not imply that consumers will never experiencepsychiatric symptoms again; we are talking about anongoing process.Based on a review of the literature about recoveryand serious mental illness in the publication by Dr.Ralph, consider this ongoing process as a journeythrough mental illness to a place where consumershave the courage, skills, knowledge, and aspirationto struggle persistently with psychiatric symptomsand the impairments that can limit them from livingindependent and meaningful lives.The process of recovery involves consumers’experiencing and processing their feelings abouthaving a mental illness and the consequences ofthat illness in their lives. Consumers write andspeak of experiencing grief, frustration, loneliness,despair, and anger at God, at the mental healthsystem, and at society’s treatment of people withmental illness.As you work with consumers, it is importantto allow them to express their feelings abouthaving a mental illness. Anger, grief, frustration,hopelessness, and despair are all normal emotionsthat a person who is diagnosed with a major illnessmight experience. Be careful not to ignore thesefeelings as being merely symptoms of mentalillness, mood swings, or labile affect.Listen and validate consumers’ feelings, withoutdiscounting or minimizing their experience. Helpthem refocus on what they are able to do and howthey can decrease the symptoms they experience,prevent them from recurring, and become involvedin meaningful adult activities that interest them.Training Basic Recovery Elements Frontline and the of Staff Stress-vulnerability ACT Model 3 Module 12

Convey hopeIt is easy for a person who is diagnosed witha serious mental illness to lose hope. Thesymptoms of psychiatric illness can be verydifficult to live with. Historically, we have senta clear message that people who experiencepsychiatric illnesses are less valued membersof our society. Until recently, even the mentalhealth profession has sent the message that thebest a consumer might hope for is to “cope.”While progress is slowly being made to changeattitudes and eliminate the stigma associated withmental illness, people who are diagnosed with aserious mental illness still receive many negativemessages, which are easy to internalize. Your jobinvolves countering those negative messages byshowing the people you work with the same respectand consideration you would any adult and byhelping them to envision social roles for themselvesother than those of patient or consumer.For more than a decade, Barbara Julius directedthe Outreach Program in Charleston, SouthCarolina. She remembers her struggle coming tobelieve in the possibilities for people diagnosedwith serious mental illnesses:When the Outreach Program started, I did not havea lot of experience working with people diagnosedwith schizophrenia. When it was time for me to reviewcharts to decide if we were going to admit someoneto our program and I began to read about the bizarrebehavior and incidents that had led to people beingin the State Hospital for long periods of time, I foundmyself thinking, “Oh no! This person could never bein the community. That would be a huge risk. Whatabout our program’s liability?”During a consultation with Debbie Allness, a memberof the original program for ACT, I shared theseconcerns and I remember her saying, “If you thinkthis is impossible, maybe you shouldn’t be doing thework.” Her comment was a turning point for me. Irealized that if you cannot, as an ACT leader, holdthe dream of possibility for another person, then youshould not be leading an ACT team. If your thinkingis so restricted that you cannot envision consumersgetting better and you think they will require constantsupervision, then why do ACT?Your role is not only to help the people who receiveyour services to see a more hopeful future, but alsoto help change the attitudes of those around you.Mike Neale, who has helped to develop more than50 ACT programs for the Veterans Administrationtalks about the role of ACT team members inchanging attitudes:ACT is all about advocacy, all the time. That is themode you go into when you start doing communitybasedservices. You do not know where, when, andhow, but you know you will do it. And you need to.You need to educate everybody; all the stakeholders—from yourself, to your client, family members, othersout in the community, other providers, and providerson your team, providers back in your system, andcommunity members. It is the whole spectrum ofeducation about what you do, what the potential is forpeople diagnosed with a serious mental illness, andhow mental health treatment can work. Essentially,you are trying to change perception and behaviors atevery level.Module 12 4 Recovery and the Stress-vulnerability Training Basic Elements Frontline of Model Staff ACT

Understand the Stress-vulnerability ModelThe ultimate goal of ACT is to help consumersreach a point where having a mental illness is notcentral in their lives. To help them reach that point,you must understand something about the onset andcourse of mental illness. The Stress-vulnerabilityModel gives you a framework for thinkingabout mental illness; it is a practical schema forconceptualizing the objectives of services.According to the Stress-vulnerability Model,an episode of major mental illness, such asschizophrenia, schizoaffective disorder, bipolardisorder, or major depression, involves two factors:biological vulnerability, and stress. For peopleto develop a mental illness, they must have thebiological vulnerability for that particular illness.The illness may then develop spontaneously orwhen they are exposed to stress. Triggered bystress, the illness may reoccur periodically.In some consumers with severe disorder,vulnerability appears to increase with repeatedepisodes of illness. The criteria for admission toACT programs makes it particularly likely thatconsumers who receive ACT services will havehad multiple episodes of illness and experiencesymptoms that may not fully remit.Stress-vulnerability ModelBiologicalFactorsVulnerabilityStressorsPsychiatricsymptomsResearchers are not certain of the exact precursorsof biological vulnerability, but some researchimplicates genetics, biochemical agents, and earlybiological development.On the other hand, stressors are something withwhich everyone is familiar. Look at the list ofstressors in Table 3. Some stressors are majorunpleasant life events, such as losing a loved one,being fired, losing your home, being arrested, andbeing hospitalized.Table 3: Stressors and Susceptibility to StressStressorsSusceptibility to stressMajor negative Major positive Everyday Increase Decreaseevents events hassles susceptibility susceptibilityMajor illness A new home Deadlines Not feeling well Good healthHospitalization Hospital discharge Rude people Being tired Adequate restSerious injuryVictimizationLoss of your homeDivorce or separationHaving a child takenawayArrest orincarcerationLoss of a jobFamily crisesA new babyRelease from jailA new relationshipGetting marriedStarting a new jobA promotionA pay raiseGiving upaddictive drugsForgettingsomethingimportantTrafficCranky childrenPaying billsNot receiving acheck on timeBeing hungryNoisy livingenvironmentCrowded livingenvironmentSocial isolationNegative or pessimisticattitudeLack of meaningfulstimulationAdequate nutritionAdequate financialresourcesSocial supportOpportunities to relaxExercisePositive or optimisticattitudeTraining Basic Recovery Elements Frontline and the of Staff Stress-vulnerability ACT Model 5 Module 12

Stressors can also be events and experiences thatare generally considered positive or desirable.For example, being discharged from the hospital,being released from prison, giving birth to a child,receiving a job promotion, getting an increase inpay, and starting a new relationship are experiencesthat would generally be considered changes for thebetter. The key is that they involve change. Evenwhen it is for the better, change can be stressful.Stressors do not always have to be major events.Daily hassles, such as traffic jams, cranky children,rude people, or deadlines can also be stressful. Attimes, people may be particularly susceptible tostress. Sometimes even little things that normallywould not bother people can be stressful, suchas feeling hungry, tired, lonely, or ill (as shown inTable 3).Some conditions and circumstances make it easierfor people to cope with stress; for instance, whenthey are getting exercise, proper rest, and goodnutrition. Social support — having people who willlisten and offer support when things are not goingwell — can also make it easier for people to copewith stress.Implications for interventionConsidering the basic premise of the StressvulnerabilityModel, you could conclude that whenpeople who are biologically vulnerable to mentalillness encounter stressors, they risk relapse.Logically then, interventions that change someone’sbiochemistry, exposure risk, and factors thatinfluence susceptibility to stressors can favorablyalter a person’s odds of experiencing psychiatricsymptoms (and chances of reaching a point wherelife does not center around mental illness).Change consumers’ biochemistryOne way to alter the stress-vulnerability equationis to alter biological processes. Medications canalter the workings of chemicals within the brain toreduce or eliminate psychiatric symptoms. Thesemedications can have substantial side effects andusing them effectively requires a close workingrelationship between consumers and their doctors.Drugs and alcohol also affect the chemistry inthe brain and can worsen psychiatric symptoms.Effectively addressing psychiatric symptoms meansalso treating co-occurring drug and alcohol abusedisorders.Change consumers’ risk of exposureto stressorsMajor negative life experiences, such as jobloss, arrest, and injury, are likely to be commonexperiences among people in ACT programs. Whenconsumers initially enter the program, the team willfocus on helping them through the aftermath ofthese experiences.To change consumers’ exposure to stressors, youmust think ahead about what skills, support, andresources people need to prevent such events fromrecurring. For instance, perhaps you can avoidfuture evictions by helping consumers devise andcarry out a plan to pay their rent on time or bycoaching them to keep their apartment reasonablyclean.Perhaps you can help avoid future arrests throughcoordinated interventions that include helpingconsumers occupy their time with activities thatprovide alternatives to using illegal substances.The Comprehensive Assessment and Psychiatric/Social Functioning History Timeline (We discussthis in detail in module 3) can help your teamanticipate antecedents of these negative life events.You can use this information to inform approachesto prevent these stressful events from recurring.Module 12 6 Recovery and the Stress-vulnerability Training Basic Elements Frontline of Model Staff ACT

Confront some stressorsThere are some stressors that people may not wantto avoid, for example, moving to a new apartment,being discharged from the hospital, or finding anew job. In these instances, your team will want tothink about how to make the changes less stressfulfor consumers.One approach to managing positive events is tobreak them into manageable pieces. For instance,the move to a new apartment might begin with theconsumer spending part of a day there with familiarpeople. On the next visit, the consumer’s supportersmight stay for only part of the time. The next stepmight be for the consumer to spend time in theapartment alone, eventually spending a night alone.Starting a new job might be done similarly. Theconsumer might spend increasing amounts oftime on the job, gradually reducing the amountof immediate support until the consumer iscomfortable in the situation. These types ofinterventions — and the need for them —will vary from consumer to consumer.Help consumers deal with hasslesNot all stressors are major events. Life is full ofhassles that can be sources of stress. Some may beeasier to deal with if you can anticipate them; thenyou can plan to either avoid the hassles or you canrehearse strategies for coping with them.For instance, if traveling to a job during rushhour is intolerably stressful for a consumer, yourteam might want to help that person plan to leavework at a different time to miss the rush. Anotheralternative might be to rehearse a conversation thatthe person might have with a job supervisor aboutstarting work at a different time.Team members might also help consumersrecognize signs of stress and practice ways to relax.For instance, the consumer might decide to trylistening to quiet music on a headset when a signof stress appears.Change factors that influence susceptibilityto stressTable 3 also listed factors that affect people’ssusceptibility to stress, such as health, nutrition,social support, and attitude. One approach toreducing the likelihood of psychiatric symptomsis to focus on ensuring that consumers have goodphysical health, adequate nutrition, and proper rest.Because of the psychiatric symptoms andrelated cognitive and social impairments peopleexperience, it may be difficult for consumers toorganize and carry out basic activities to carefor themselves and their homes. For instance,proper nutrition involves planning which foods topurchase, managing a budget, traveling to the store,selecting food, paying for it, bringing it home, andpreparing it. Fatigue and disorganized thinking maymake it difficult for a consumer to plan and followthrough on the steps involved in purchasing andpreparing food.Similarly, in part, good physical health requiresbeing able to communicate health concerns andfollow through on treatments for medical problems.Psychiatric symptoms and associated impairmentscan make this difficult.According to Allness & Knoedler, side-by-sidehelp and support are effective in motivating andhelping consumers restore activities of adult rolefunctioning (Allness & Knoedler, 2003). Side-bysidehelp and support mean that team membersactively participate with consumers to plan andcarry out any activities to live independently, work,and socialize.Training Basic Recovery Elements Frontline and the of Staff Stress-vulnerability ACT Model 7 Module 12

Module 12 8 Recovery and the Stress-vulnerability Training Basic Elements Frontline of Model Staff ACT

Exercise: Practice What You’ve Learned About StressorsRead about Mr. Jones in the Comprehensive Assessment on the next page. In the list of stressors below,identify which factors Mr. Jones experienced in the year before the assessment. Which were present whenthe comprehensive assessment was done?Stressors and hassles that influenceMr. Jones’ susceptibility to stressDuring the past yearWhen the comprehensiveassessment was doneIllness or injury to self o oIllness or injury of loved one o oMoving o oPoverty o oDiscrimination o oHospitalization/Discharge o oFamily crises o oChanges in employment o oNew baby o oArrest or incarceration o oDeath of a loved one o oVictimization o oLoss of an important relationship o oSocial isolation o oLack of meaningful stimulation o oPessimistic environment o oInadequate rest o oPoor nutrition o oConflicts o oSubstance abuse o oGiving up or reducing substance use o oFeeling rushed o oCrowded living conditions o oNoisy living conditions o oLack of privacy at home o oMarriage o oTraining Basic Recovery Elements Frontline and the of Staff Stress-vulnerability ACT Model 9 Module 12

Module 12 10 Recovery and the Stress-vulnerability Training Basic Elements Frontline of Model Staff ACT

Sample Comprehensive AssessmentPart 1:Psychiatric History, Mental Status and DiagnosisClient name: Mr. JonesDate of evaluation: 9/30/99Reason for admission (chief complaint) as stated by consumer, family, and/or referring agency:“The Sheriff’s Department injected me with germ warfare, causing these sores.”History of present illness:Mr. Jones is a 48-year-old, black male who was referred to the ACT team for after-care following his releasefrom a State hospital due to his diagnosis of schizophrenia, paranoid type. He has significant functionalimpairments. He has:n a high use of acute psychiatric hospitalizations,n persistent recurring symptoms,n a co-existing substance use disorder, andn a recent history of involvement with the criminal justice system.Previous State hospital records indicate that he was released from a maximum-security forensic unit (releasedate 8/27/99) after being found incompetent to stand trial for alleged felony assault. He was transferred tothe State hospital for treatment and released on 9/29/99.Mr. Jones was admitted to the State hospital forensic unit in 7/88 after facing charges of aggravated assault.Jones states that, while on the forensic unit, he made suicidal gestures, such as slashing his neck with a razorblade, due to auditory hallucinations. He reported attempting to commit suicide 5 or 6 times in jail by slicinghis arms with sharp instruments, sticking pins into electrical outlets, overdosing on pills, jumping off things,and setting himself on fire.The client’s first encounter with the legal system occurred in 1975, when he shot a friend in self-defense.After that time, he began to drink heavily and use street drugs. He served time in the Department ofCorrections in 1976 for robbery and again in 1984 for aggravated assault. While in prison for aggravatedassault, he was diagnosed with schizophrenia and placed on Haldol and Sinequan. He reported a goodresponse to Haldol and was described as quiet and cooperative. He is afraid of what might happen if hegoes to prison again and believes that the State syndicate has a contract out on him for $10,000.Training Basic Recovery Elements Frontline and the of Staff Stress-vulnerability ACT Model 11 Module 12

The police department records from 6/8/98 indicate that Jones was threatening to cut people with a knifeat his apartment. He was found to have three outstanding warrants. Police noticed a strong odor of alcohol.Jones attacked the officers. He was not affected by pepper mace. After being handcuffed, Jones stated thatthe police were going to burn in a volcano and that he was going to light the fire.Correctional Medical Services notes from 8/98 indicate Jones was treated with Haldol for schizophrenia, buthad been refusing medications. He is described as acutely “decompensated.” He constantly talks about Jesusand devils. He complains about vampires. He refused antibiotics for his impetigo.A letter from Dr. H. (who saw Jones 10/98) describes Jones as “extremely labile and frequently quite hostile.”He was loud and demanding. He had improved after a recent hospitalization during which he receivedHaldol, but again decompensated. He was religiously preoccupied and delusional.A court order from 11/9/98 indicates that a jury found him incompetent to stand trial and he wassubsequently committed to the State hospital.A report from the county jail indicates that Jones was treated with Haldol and Cogentin for paranoidschizophrenia that is complicated by “non-compliance.” The jail indicates that Jones is very unpredictableand goes through mood swings. He exhibits paranoia and is delusional at times. He thinks that he is Christand will accuse others of being the devil. He picks hair out of his head and beard and has little round areasof pink skin where he no longer has any hair. He can be aggressive and a couple of days ago he tried to hit anurse with his fist. He does not like to wear clothes.Service system records indicate numerous previous psychiatric hospitalizations, including 5 admissions tothe State hospital and 14 to XX medical center. He has been offered outpatient treatment since 1992. Otherpast diagnosis includes psychotic D/O, NOS; organic hallucinosis; adjustment disorder; and undifferentiatedschizophrenia.He states: “I was charged with murder in 1976, but all I did was pull the trigger.” He reports that he hasAIDS (a delusion) and stomach viruses from drinking out of toilets. He has 19 past admissions but only 4 ofthem longer than 2 weeks. When asked about substance abuse, he states: “I can’t get them enough.” He hasnumerous self-inflicted scars on his arms. He reports that he hears voices and is Jesus Christ. He believesthat he has bugs crawling inside and outside of his body. He also believes that staff have tried to kill him inthe past.He is difficult to interview and gives rambling statements. He reports that he is a victim of a conspiracyinvolving Satan and the County Sheriff’s Department to infect him with germ warfare. He states that hehears voices of the devil and the Holy Spirit. He reports that this occurs all of the time and that he is notbothered by these experiences. He states that the voice says, “Stick ice picks in my eye and I’m going toeat you in the microwave.” When asked to elaborate on these symptoms, he became agitated, hostile, andthreatening. He will not discuss any other psychotic symptoms. He denies any symptoms of depression butreports 2 previous suicide attempts by cutting his forearm. He states that he has not been suicidal in manyyears. He denies any symptoms of mania, panic attacks, or memory impairment. Recently he reports that heis doing poorly, which he attributes to being infected with germ warfare.Module 12 12 Recovery and the Stress-vulnerability Training Basic Elements Frontline of Model Staff ACT

Treatment goals and individual strengths as stated by the consumerJones states that his goals are:nn“Find a doctor that can get rid of these germs that the County Sheriff’s Department injected me with.”“Get me some money so that I don’t have to eat out of trash cans and sell drugs for food.”n “I want to stay out of jail and the hospital because people are out to get me there. A man can’t live his wholelife that way.”Jones states that his strengths are:nnn“I know that I can survive on the streets because no one is going to mess with me.”“I’m a smart man.”“People like me.”History of past mental and psychiatric illness:County Jail(1975)Department ofCorrections(1976-1983)Department ofCorrections(1984-88)Shot a friend in self-defense. Shortly thereafter, he began drinking heavily andusing street drugs. His sister reports that Jones was “never quite right as a childand had lots of problems in school and at home.” She reports that he used to drawfunny pictures on everything – “they looked evil.” She feels that his first divorcetriggered an increase in alcohol use and led him to the situation where he wasarrested after killing his friend. She states that he “went down hill from there.”Convicted of armed robbery. Jones spent 2 months in the psychiatric unitand received the diagnosis of Psychotic D/O, NOS during this incarceration.Reports indicate that he would be fighting with “spirits” and was saying thatthe “devil was coming to get him.” Doctors tried him on Thorazine whichhelped to clear up the hallucinations, but he experienced a reaction to themedication and was transferred to the medical unit. Reports indicate that hewas not restarted on another antipsychotic following this episode. During histime in the community, Jones married again and later divorced. He says thathis ex-wife just did not understand him and refused to believe that the “devilwould kill them one day.” He stated that they would stay barricaded for daysin their apartment to stay safe. He feels that this led to their divorce.Convicted of aggravated assault. First diagnosed as having schizophrenia. Reportsindicate that Jones had a serious suicide attempt while incarcerated. He wasbeing tormented by voices, which he believed to be the devil telling him thatthe State syndicate was coming to cut off both his hands and gouge out his eyes.He self-inflicted deep cuts across his jugular veins. He was treated with Haldoland Sinequan. This reportedly helped to alleviate some of the symptoms anddecreased the aggressive acts.Training Basic Recovery Elements Frontline and the of Staff Stress-vulnerability ACT Model 13 Module 12

State Hospital(4/14/88-7/1/88)Department ofCorrections(1988-92)County MHMR(2/7/92-11/1/93)County Jail(1993)Charged with aggravated assault and unauthorized use of a motor vehicle. Duringhis stay, he received Haldol-D injections, Ativan, and Cogentin. The forensicpsychiatrist felt that he was not actively psychotic at the time of the aggravatedassault and that he was able to understand court proceedings. He was dischargedas competent to stand trial and then convicted of both charges and incarcerated.Jones reports that he was high on “crack” cocaine at the time of the murder andthat the scene was related to a drug deal.During this period, Jones was incarcerated at the psychiatric facility. It is reportedthat he exhibited “fixed” delusions the entire time he was there, related to thedevil trying to kill him. His hallucinations decreased with an “adequate” dose ofHaldol-D. His aggressive behaviors decreased as well, although he continued tobe confrontational with staff as well as other inmates. Staff reports that he sufferedseveral injuries related to retaliation from inmates. He did not actively participatein substance abuse treatment and continued to deny problems in this area.It is reported that Jones showed up for one after-care appointment, received aninjection, and did not show up for any other appointments.Felony assault of a police officer. Jones reportedly resisted arrest when beingquestioned in a “drug-related” situation. The report indicates that he was verballyaggressive stating “that the devil would not receive him tonight and that thepolice would die for helping the devil.” He reportedly caused extensive injury toone officer, who required several days of hospitalization (i.e., a broken wrist andbruising to the face). Charges were dropped and he was released.Hospitalizations Medical Center (11/4/93 – 11/19/93)Medical Center (11/26/93 – 12/5/93)Medical Center (2/4/94 – 2/15/94)Medical Center (8/20/94 – 8/29/94)Medical Center (11/1/94 – 11/5/94)Medical Center (1/12/95 – 5/4/95)Medical Center (6/28/95 – 7/6/95)Medical Center (8/21/95 – 8/28/95)State Hospital (8/28/95 – 9/8/95)Medical Center (3/1/96 – 3/5/96)Medical Center (7/19/96 – 7/30/96)State Hospital (10/4/96 – 12/1/96)State Hospital (12/13/96 – 2/8/97)Medical Center (5/17/98 – 5/24/98)Module 12 14 Recovery and the Stress-vulnerability Training Basic Elements Frontline of Model Staff ACT

In the review of the hospitalizations at the Medical Center and the State Hospitallisted above, a significant pattern is noted. Symptoms include Jones verbalizingthat, “Vampires from England attack him and he believes he is Jesus.” He isirritable and threatening and believes that the Medical Center barbeques people.Medications that were tried were Zyprexa, Risperdol, Seroquel, and Haldol. Itappears that when he was released, there was never any follow-up and housing wasan ongoing issue. Notes from the hospital indicate repeatedly that he was “noncompliant”with his medications and follow-up. In speaking with the SalvationArmy, it was reported that Jones was released to their charity but could only spend3 days at a time there per their policy/procedure. The County Sheriff’s Departmentreports many “criminal trespass” arrests during this time as well.It appears that Jones’ symptoms are never adequately treated and that trials on thenew-generation antipsychotics are short with no supervision upon release fromthe hospital. In assessing Jones, it appears that due to his symptomatology, he isnot organized enough to take his oral medications independently or meet his basicneeds. His survival techniques included rotating through the hospital, jail, andtemporary shelters. His interactions with others were threatening.County Jail(6/8/98-11/19/98)State Hospital(11/20/98-8/27/99)State Hospital(8/27/99-9/29/99))Mental StatusExam:While in jail, he was prescribed Haldol-D and Oral plus Cogentin. He refused theinjection. It was reported by staff that he was “arrogant, and believing the devil isin him.”Committed to Maximum Security Unit after being found incompetent to standtrial for the alleged offense of Assault Causing Bodily Injury/Assault to a PublicServant. It was reported that Jones continued throughout his hospitalization tomaintain psychotic symptoms with delusions and hallucinations. He was alsodescribed as easily agitated, impulsive, potentially explosive, and unpredictable.He was described as treatment- resistant. It was recommended to the court thathe would not likely become competent within the near future. His medicationsincluded Gabapentin 900mg bid, Ativan 1mg bid, and Risperidone 5mg bid.Transferred from the State Hospital after the felony charges were dropped toallow for further treatment. Reports indicate that Jones was aggressive and easilyagitated toward staff. He was verbally loud and escalated easily. He was alsoengaging in self-talk and laughter at levels suggestive of auditory hallucinations.The patient was lucid, oriented, coherent, and alert. He was groomed casuallyand appropriately with good hygiene. His hair and beard were appropriatelytrimmed. His mood was labile. Initially his mood was mildly elevated, but he wasaccommodating and patronizing. However, he showed ease of agitation withoutapparent provocation, especially when upset. He was easily frustrated. Duringthe interview, he became angry and this escalated to cursing with loud, shoutingspeech. At the end of the interview, he stalked angrily out of the room, cursingas he went and slammed the door. His speech was loud, rapid, continuous, andpressured. He acted demanding, irrational, and was easily confused.Training Basic Recovery Elements Frontline and the of Staff Stress-vulnerability ACT Model 15 Module 12

His thought processes were disorganized and he could not be engaged inmeaningful or substantive conversation in areas related to his mental illness orhis offenses. He was preoccupied with his delusional thoughts. These delusionsincluded religious, satanic, and paranoid themes. For example, he said “Satanattacked me in jail and said he was going to stick an ice pick in my eyes and cutme with a chainsaw. He made me cut my jugular vein… I hear the Holy Spirit.Once it’s in you, it stays with you... I’m not going to talk about hearing the angels.I know not to… This is a conspiracy.” Jones admitted to racing thoughts. Hewas paranoid, explosive, and unpredictable. He was not threatening to self, andnot felt to be suicidal. He was hallucinatory, and admitted to hearing angels. Hismemory was difficult to assess due to his active psychosis. His eye contact was fair.His psychomotor activity was increased with his agitation. He said, “Taking thempills or not taking them pills, I feel the same way.”Diagnosis (SCID completed)Axis IAxis II295.30 Schizophrenia, Paranoid Type; Polysubstance Dependence301.7 Antisocial Personality Disorder with Borderline featuresAxis III History of Exposure to Hepatitis A, B, and C, as validated bylaboratory studiesEsophageal RefluxNon-Tuberculosis MycobacteriumAxis IVAxis V 30A, B, C, E, H, IRecommendations for treatment planThe overall psychiatric rehabilitation goal is for Jones to function more independently in the community andcope more effectively with stressors without resorting to the use of chemical substances that will cause himto have further conflicts with the law.It is recommended that Jones see the ACT psychiatrist a minimum of every month to monitor symptoms,side effects, and medications. His primary advocate on a weekly basis will provide psychoeducation duringmedication training in order to enable Jones to communicate the need for medication changes. Medicationswill be monitored daily with continuous monitoring of suicidal/homicidal ideation. Collaboration with thelocal law enforcement agencies to ensure the safety of the community and staff is maintained. Assertiveattempts will be made to change the pattern of hospitalizations/jail/homelessness and to treat symptoms witha new-generation antipsychotic medication.Module 12 16 Recovery and the Stress-vulnerability Training Basic Elements Frontline of Model Staff ACT

Part 2:Physical HealthPast medicalhistory:Surgical history:Substance abusehistory:Other significantsocial factors:Records show that he has no major health problems. History of exposure toHepatitis A, B, and C, as validated by laboratory studies; esophageal reflux; non-Tuberculosis MycobacteriumRecords show he has no previous surgery.The patient reports past use of cocaine, marijuana, LSD, alcohol, and othersedatives.Sexual: HeterosexualCurrent medications: Haldol and CogentinAllergies: NoneFamily history: He denies knowledge of any major health problems with family members. Contactwith family should be made to verify. He reports that both his mother and fatherhave died and that he has nine sisters who refuse to have contact with him. Hestates that he has three children but does not know where they are living.Height: 6' 2"Weight: 155Blood pressure: 120/70Significantoccupationalexposure:Travel history:Prosthetic devices:NoneU.S. onlyNoneReview of systems: n Special senses: Vision, hearing, taste, and smell are preserved.n Neuromuscular: Denies any history of head concussion, seizure disorder, orparalysis.n Cardiorespitory: Denies any history of chest pain, cardiac arrhythmia,palpitations, bronchitis, or pneumonia.n Gastrointestinal: Denies any history of dysphagia, peptic ulcer disease,hematemesis, or melena. Does report a history of esophagealreflux.n Genitourinary:n Gynecologic/Menstrual:n Endocrine:n Fractures:Denies any history of kidney stones or kidney infection.N/ADenies any history of diabetes.Denies any history of fractures.At physical examination, this patient is alert, active, somewhatcooperative, delusional.Training Basic Recovery Elements Frontline and the of Staff Stress-vulnerability ACT Model 17 Module 12

Appearance andnutrition:Skin:Head:Eyes:Ears:Nose:Mouth:Neck:Chest:Breasts:Heart:Vascular system:Lymphatic system:Abdomen:Genitalia:Anus/rectum:Pelvic:Trunk andextremities:Neurological exam:Cranial nerves:Motor system:Sensory system:Cerebellar:He appears to be malnourished and underweight.There are multiple sores on face, neck, and extremities, which are self-inflictedtraumatic sores; there is a tattoo on right arm; there is no evidence of major scars.Normal cephalic; face is symmetrical; scalp is normal except for some sores thatare also self-inflictedConjunctivae are pink; sclera are white; pupils are equal, round, they react to lightand accommodation; there is no ptosis; there is no nystagmus; the extraocularmovements are normal; vision is 20/20 both eyes without glasses.External ear canals are clean; tympanic membranes are normal; able to hearconversational voices and the vibrating fork.In the midline there were no obstructions.Oral mucosa is moist, throat is clearNo enlarged thyroid; no vein engorgement; no palpable lymph nodes; range ofmotion of the C-spine is normal.Lungs are clear.No masses felt.Regular.In upper and lower extremities, all pulses are present; there is no evidence ofvaricose veins.There is no evidence of lymph edema or enlarged lymph nodes in groin, axillae, orsupraclavicular areas.Soft: nontender; no masses felt.Of a male.The patient declined to be checked.Not applicable.Range of motion of all joints in upper and lower extremities is normal.Alert and oriented; uncooperative and delusional.Pupils are equal, round, they react to light and accommodation; there is no ptosis;there is no nystagmus; the extraocular movements are normal; facial muscles aresymmetrical without weakness; tongue is in the midline with normal movementand the deglutition mechanism is preserved.In upper and lower extremities, good muscle strength and development; fine andgross manipulation and grip strength are normal; gait in terms of speed, stability,and safety is normal.Vibration, pain and temperature can be felt.Finger to nose and tandem gait are normal; Romberg is negative. Reflexes inupper and lower extremities are brisk and symmetrical; no abnormal reflexesfound.Module 12 18 Recovery and the Stress-vulnerability Training Basic Elements Frontline of Model Staff ACT

Personal RoutineOral hygiene:Shampoo/Bathing:Sleep:Sexual:Substance use:Jones reports that he brushes his teeth when he has a toothbrush and toothpaste.His transitory history has affected this area.Jones reports that when he has access to facilities, he enjoys being clean andbathes daily.“I don’t keep track of time except when the sun rises and the sun sets.”Jones reports that he is currently sexually active and prefers “many different”women. He states that he uses a condom each time because he reports that heis HIV positive. (Tests do not confirm this.) He reports “he learned his lesson”when he had chlamydia and “practices safe sex now.” He denies a history of sexualabuse.Jones reports that he smokes at least a pack of cigarettes a day and more if he canget them. He reports that he has smoked since he was 14 and has no complaintsof shortness of breath or persistent cough. He states that he drinks 1-2 caffeinateddrinks. He states that he drinks alcohol on a daily basis, if available, and prefersbeer. He reports that he enjoys using marijuana and “crack” cocaine and will useit daily if he can access it. He feels that he needs the alcohol and drugs to survivebut states he “can cut down when he needs to.”RecommendationsOngoing monitoringFollow-up with MMB in re: Esophageal Reflux, Non-TB Myobacterium, and sores on head/face.Dental appointmentPart 3:Use of Drugs or AlcoholRecords and self-report indicate an extensive history of substance abuse involving the followingAlcohol:Heroin:Sedatives:Tranquilizers:Amphetamines:Jones reports that he uses this substance daily if it is available. He has used withinthe past 48 hours. Use began at the age of 12.Jones reports that following the shooting of his friend in 1975, he tried heroinseveral times. He has not used this substance since that time.Jones reports that he has used Dalmane and Seconal after doctors at the StateHospital prescribed it for him. He states that he did not like the effects but thatthey had a “high street value.”He reports using Ativan, Valium, and Xanax. Again he reports that he did not likethe effects, but that he was able to sell these drugs on the streets.He reports using prescribed Cylert.Training Basic Recovery Elements Frontline and the of Staff Stress-vulnerability ACT Model 19 Module 12

Cocaine:Hallucinogens:Marijuana:Withdrawalsymptoms:Use patterns:Jones reports he would use “crack” cocaine on a daily basis if it were available.He began using this drug in 1988 and has used this consistently when in thecommunity and even times when he has been incarcerated. He reports he hassnorted, smoked, and injected. This is his drug of choice.Jones reports that he has used LSD, PCP, and MDMA. He has not used thesesince he has been incarcerated. He stated that he enjoyed the drug “Ecstasy” andwould use this drug again if it were offered to him.Jones reports that he has used this in the past 48 hours. He states that he startedusing this drug when he was 12. He states that it was readily available becauseother family members used it.Jones reports that he has experienced flu-like symptoms, gets sick to his stomach,gets confused, and possibly experiences visual and tactile hallucinations whenforced to quit using the substances of his choice.Jones reports that he usually uses in the morning with other people when he istense or scared. He feels that he has to use more than he used to and has beenunable to hold a job because of his use. (“No one will hire a user.”) He knows thateven though use causes his symptoms to increase, he wants to continue to usebecause that is all he knows. He knows that if he is using daily he is not able tofunction as he should, but that it helps him to forget and it stops the voices of thedevil. He states that he will not be killed if he does not hear them (the voices).Problems related to substance use and level of impairment:n Physical: Jones has received a doctor’s warning more than once toquit using substances.n Cognitive: Jones reports experiencing blackouts, memory problems, andconfusion due to use.n Affective: No reports of depression following use but reports do indicate anincrease in “manic” type symptoms.n Tolerance: An increased dose is required to get the desired effect.n Felt need: Jones reports a strong desire to use to feel “normal.”n Interpersonal Problems: He knows that many relationships have focusedaround use and who has access to the drugs. He reports that he has never had arelationship with someone who did not need to trade something for drugs. Heacknowledges that when he has committed all of his alleged crimes, he eitherhas been “drug-seeking” or has owed someone.n Aggression: He becomes homicidal when using and experiencingacute symptoms.n Vocational: Has not worked since he was 23.n Legal: Multiple arrests related to use.n Financial: “Most of my money is spent paying back people that I owe.”Module 12 20 Recovery and the Stress-vulnerability Training Basic Elements Frontline of Model Staff ACT

Treatment andabstinence history:Family substanceabuse assessment:Motivation/Confidence rating:Jones reports that he has never been treated for alcohol or drug addiction and isonly abstinent when he is incarcerated or in the hospital.Jones’ sister reports that many of his sisters have suffered severe consequencesdue to substance use, including incarceration, interpersonal problems. She alsoreports that Jones’ father was “drunk” all the timeDue to the severity of dependence and lifestyle/familial pattern, Jones is notmotivated to quit using at this time but is able to verbalize the impact that the usehas on his illness.His history shows repeated disturbances of functioning seemingly precipitated byrelatively small amounts of alcohol or drug use.Assessment summaryJones meets the diagnostic criteria for Polysubstance Dependence. Even though he has experiencedextreme consequences due to his use, this has had little impact. This is a learned behavioral pattern ofdealing with stressors and has been modeled by family members as a coping strategy.It is recommended that staff work with Jones on developing coping strategies to deal with his stressors/symptoms and to work on environmental changes. It will be of the utmost importance to develop a nonjudgmentaltherapeutic relationship with Jones to help him make better choices.Part 4:Current dailystructure:Education history:Military history:Employmenthistory:Education and EmploymentJones reports that he usually spends his day wandering the streets. When he isincarcerated, “my day is planned for me.” He states that he has a hard time doingthings because “people are watching me and the devil will come for me if I am outtoo long.”Jones graduated from XX High School in (city). He states that he does not havemany memories from school. He states that he did not have many friends andstruggled in school. People thought “I was weird.” His sister reports bizarrebehavior and that he was always drawing evil pictures. She reports that classmateswere scared of him because of his constant talk about “the dark side.” Jones is ableto read and write but states that he finds it difficult to concentrate to completesomething.He is a non-veteran.Jones reports that the only job that he has ever worked was construction. The lasttime that he worked was in 1975.RecommendationsJones states that he does not want to work at this time. Staff needs to identify his interests and work withhim on “adult role functioning” that is not related to drug use.Training Basic Recovery Elements Frontline and the of Staff Stress-vulnerability ACT Model 21 Module 12

Part 5:Social Development and FunctioningJones and his sister report that he was born and raised in (city, State). He has 9 siblings all of whomare sisters. He is in the middle of the birth order. He feels that he was left to “raise himself.” He statesthat his dad was “drunk” all the time and that his mother would cry. He stated that his father was in jailseveral times and that his mother had to live on welfare. He states that his father beat his mother andthe children. He states that he does not have any good memories from childhood and that he never hadany friends when he was a child. He graduated from XX High School. He states that he liked being aloneexcept when he needed to “satisfy his manly urges.” When he was older, he and his friends drank beerand smoked pot on a regular basis – “That was the only thing we had to do.”He states that the only friends he has now are people who owe him. He feels it is not “worth it” to bein a relationship. He has been married 2 times and divorced. His first wife divorced him after he wascaught messing around on her and beating her because she was possessed by the devil. His second wifedivorced him, he feels, because she would not believe him when he told her the devil would kill themand he would barricade them in the apartment for days at a time. He has 3 children with whom he hasno contact.Culture andreligious beliefs:Leisure activities:Social skills:Legal involvement:Both of Jones’ parents are of African-American descent. When he is asked wherehe was raised, he states that he was raised overseas. (His sister reports that thisis inaccurate.) Jones reports that the “white” people discriminate against him,that the KKK is out to get him, and that the State syndicate will track him downand kill him. When asked about religion, he stated that he is Jesus Christ andverbalized how the angels and devils are beneath him when he is all-powerful.Many of his delusional thoughts are fixated around his belief that he is persecutedbecause of his race and the belief that he is Jesus.Jones reports that it is difficult for him to concentrate for long periods so hespends his time walking. He states that he does not watch TV because that is “theway that they gather information on you.” He reports that he will go to a bar to“find him a woman.”Jones feels that if you behave in a threatening manner, you will get what you want.He reports that he gets into fights all the time and the police are always called tohandle things. He states that people “piss him off” all the time and that he reallydoes not like anyone. He has multiple arrests related to his aggressive responses.See Part 1 of this assessmentRecommendationsDue to the majority of his adult life being spent in institutions, extreme paranoia, and his delusionalthought processes, Jones does not have the skills to function/interact independently in a community ina successful manner. Staff will need to help him develop coping strategies in-vivo. Due to the negativesymptoms related to his illness, Jones is not able to identify “healthy” leisure choices. Staff will help himto identify interests and then help him pursue these choices during weekly 1:1.Module 12 22 Recovery and the Stress-vulnerability Training Basic Elements Frontline of Model Staff ACT

Part 6:Activities of Daily LivingLivingarrangements:Eating habits/food preparation:Grocery shopping:Diet and exercise:Grooming:Laundry:Moneymanagement:Housing:Jones is currently homeless. He states that he wants to live by himself in (city).He reports that when he is not in the hospital or in jail, he has lived on the streetsor has gotten “dive” apartments, staying no longer than a month before beingevicted. Prior landlords report that evictions occur due to “aggressive” threats toother tenants, poor upkeep of the apartment, and alleged drug trafficking.Due to his extensive history of institutionalization, Jones has not been required toprepare his own meals. When he has been homeless, he reports that he will eatwhatever he can get. He would like to eat 3 meals a day with “lots of meat.” Hestates that he is not able to cook well but can make things like sandwiches and thathe can barbeque. He feels that he will need assistance in learning these skills. Ithas been noted that he has been able to trade food items for beer and drugs.During contacts at the store, Jones is unable to complete the task due to hisparanoia and unable to prepare a list due to his disorganized thoughts.He has a history of being malnourished due to lack of access to nutritional foodsand due to his beliefs that food is poisoned and then not eating. Treatment ofparanoid symptoms and monitoring of his eating habits and weight will be of theutmost importance.Jones reports that he wants to take daily baths. He states that he has to take themfrequently at times “because there are bugs crawling out of my skin and I have toget them off.” He has infected sores on his skin due to continuous picking at hisscalp and face. He requires verbal prompting to remember to use all the groomingitems such as shampoo and soap.Jones does not know how to use the laundromat facilities and needs physicalprompts and reminders to complete the task. He does not like to spend his moneydoing laundry. He is limited in his clothing and staff will need to assist him inpurchasing new clothes.Jones’ current monthly income is his SSI check of $509. In the past, when he hasreceived the check himself, he would spend the entire amount in 1 week primarilyon drugs and then present himself in the ER for admission to the psychiatric unit.His payee will now be Guardians Are Us to ensure that his check is spent on hisbasic needs. He will complete a monthly budget with staff assistance.Jones will be responsible for housekeeping tasks where he lives. He reports thathe has a hard time keeping places clean because he cannot organize well. Hestates that he cannot get motivated and at least he is not living in a dumpster.RecommendationsDue to the severity of Jones’ symptoms (i.e. paranoia, avolition, poor concentration) and extensive timespent in an institutional setting, he will require extensive support in all areas of ADLs. Jones reports thathe would like to stay in one apartment for 6 months without being evicted. He feels that he will needdaily supports to do this in the areas of housekeeping, money management, and apartment maintenance.He also will require ongoing monitoring of his diet to ensure that he is eating properly.Training Basic Recovery Elements Frontline and the of Staff Stress-vulnerability ACT Model 23 Module 12

Module 12 24 Recovery and the Stress-vulnerability Training Basic Elements Frontline of Model Staff ACT

Exercise:Practice What You’ve Learned About Treatment Planningand the Stress-vulnerability ModelRead the treatment plan on the next page that was developed for Mr. Jones. Then review each action stepidentified in the plan and decide which step addresses each of the changes shown. Check all that apply.Check all that applyA B C DAction stepChange theperson’sbiochemistryChange theperson’s riskof exposure tostressorsChange theperson’ssusceptibilityto stressorsOtherSee MD every 4-6 weeks for prescriptions,symptom assessment, supportive therapies o o o oHave daily contact with Integration Specialist (IS)to assess symptoms and develop coping strategies(e.g., anger management, environmental issues)o o o oBe available 24/7 for crisis response andsupport services o o o oMeet monthly with IS to educate Mr. Jones aboutrelationship between mental health and behaviors,involvement in criminal justice system, anddeveloping coping strategieso o o oSchedule a one-to-one motivational interview 3times a week with substance abuse specialist o o o oAttend weekly dual diagnosis group at ACTprogram office o o o oFind safe, affordable housing o o o oHave weekly contact to monitor apartmentmaintenance. Adjust, as needed o o o oMeet monthly to review budget and liaisonwith payee, as needed o o o oMonitor food supply, trips to grocery,and education about nutrition o o o oTraining Basic Recovery Elements Frontline and the of Staff Stress-vulnerability ACT Model 25 Module 12

Module 12 26 Recovery and the Stress-vulnerability Training Basic Elements Frontline of Model Staff ACT

Sample Treatment PlanUse this treatment plan to complete this exercise. These exercises are intended to reinforce ACT practiceprinciples and skills. The Sample Treatment Plan is not intended to serve as a model; separate SAMHSAsupportedinitiatives are currently underway to create model individual treatment plans of care.ACT Treatment PlanPrimary treatment team: Sally S., Integration Specialist (IS)Fred F., Substance Abuse Specialist (SAS)Jane J., Employment Specialist (ES)Nancy N., Nurse (RN)Mike M., Psychiatrist (MD)Name: Mr. Jones SSN: 123-45-6789Tx Plan Date: 10/21/99Review Date: 4/21/99Discharge criterion:1. No significant major psychotic or affective symptoms for 2 years,and2. No major role dysfunction in areas of work, socialization, andself-care for 1 year under conditions of minimal treatment.DSM IV DiagnosesAxis I295.30 Schizophrenia, Paranoid Type304.80 Polysubstance DependenceAxis IVPsychosocial Stressors: Rejection by familyInadequate social supportUnemployedInadequate housing/unsafe neighborhoodMultiple arrests/convictionsHostile relationships w/othersSeverity:3 – ModerateAxis II301.7 Anitisocial Personality Disorder w/Borderline FeaturesAxis IIIHistory of exposure to Hepatitis A, B, & Cas validated by laboratory studies;Esophageal refluxNon-tuberculosis mycobacteriumAxis VCurrent GAF: 30Highest GAF past year: 30Strengths1. Survival skills developed while living on the streets2. High school diploma3. Desire for more stability in his life4. Engaging personalityFocus Area 1Jones’ experiences:1. persistent delusional thoughts of a religious, satanic, and paranoidtheme (i.e., “The County Sheriff’s Department injected me withgerm warfare.” “The devil is trying to kill me.”)2. persistent auditory hallucinations (Satan or the Holy Spirit aretalking to him) which, at times, command him to harm others orhimself (Mr. Jones has a history of suicide attempts and two felonyarrests for murder);3. periods of unpredictable agitation, leading to cursing with loudshouting speech and implicit threats to others;4. when acute, hallucinations and delusions increase with an increasein impulsive acts (often leading to misdemeanor arrests);5. symptoms become worse with the use of alcohol and illegalsubstances.Goal Trial of new-generation medication (Risperdal) to better controlpsychiatric symptoms while minimizing side effects. Mr. Joneswill take medications consistently as prescribed to allow for anadequate trial, or communicate a need for a change 90% ofthe time through 10/00 as measured by staff observation anddocument in progress notes.Goal Through 4/00, Mr. Jones will have no incidents of unplannedhospitalization as measured by staff, community, and crisisreport.Training Basic Recovery Elements Frontline and the of Staff Stress-vulnerability ACT Model 27 Module 12

Plan1. MD to see every 4-6 weeks for medication prescriptions,symptom assessment, and supportive therapies;2. Daily 1:1 with IS for symptom assessment, medication education3. Weekly 1:1 with IS for psychoeducation, Sx assessment, anddevelopment of coping strategies (e.g., anger management,environmental issues); and4. ACT team to be available 24/7 for crisis response, support services.Focus Area 2History of involvement with the criminal justice system including3 felony convictions, multiple arrests, and hospitalizationsPlan1. IS to meet monthly with Mr. Jones for 1:1 on the relationshipbetween his mental health and behaviors and involvementin the criminal justice system and develop coping strategies.2. IS and SAS to interact with law enforcement officials to provideeducation about mental illness and function as liaison, as needed.Goal Through 10/00, Mr. Jones will have no arrests or physicalaltercations as measured by self, staff, community, andpolice reports.Goal Through 10/00, Mr. Jones will revisit his timeline on amonthly basis during1:1 to identify pattern and developpre-crisis coping strategies as monitored by staff report.Focus Area 3Extensive history of substance abuse which contributes to an increasein psychotic symptoms and possible suicidal/homicidal risk(see Focus Area 1). History of burglaries to obtain moneyto purchase substances (see Focus Area 2). Predominantly ETOHand “crack” cocaine use, but inclusive of LSD, PCP, MDMA,marijuana, amphetamines, tranquilizers, and sedatives. Mostrecent use was ETOH and “crack” cocaine. Substances are oftenused to “drown out the voices so I don’t have to hurt anyone.”Plan1. 1:1 motivational interview 3 x week – SAS2. Weekly dual-diagnosis group at ACT program office – SASGoal Mr. Jones will understand the connection betweensubstance use, increase in psychiatric symptoms, and arrestas evidenced by being able to verbalize the relationship tostaff on 3 or more different occasions prior to 4/00.Goal Mr. Jones will understand the dangers of combiningalcohol and other illegal substances with his prescribedpsychiatric medications as evidenced by being able toverbalize the dangers on 3 or more different occasionsprior to 4/00.Goal By 1/00, Mr. Jones will identify 1 or more factors hepersonally views as benefits from reducing or eliminatingthe use of alcohol or other substances.Focus Area 4Inability to conduct activities of daily living without consistent promptsand assists (i.e., living arrangements, money management, nutrition,housekeeping and grooming/hygiene) as directly related to Focus Area1 symptomatology, including paranoia, impulsive agitation, and poorinterpersonal social skills.Plan1. IS and SAS to work with Mr. Jones on locating affordable, safehousing.2. Weekly 1:1 with IS for apartment maintenance monitoring.(Based on need, interaction by staff will be titrated fromside-by-side assistance to verbal prompts.)3. IS to meet monthly with Mr. Jones to review budget andto liaison with his payee on as needed basis.4. Weekly monitoring of food supply/trips to grocery storeand education about nutritionGoal Mr. Jones will maintain his residence in a safe environmentfor 3 consecutive months by 10/00 as monitored by self,staff, and apartment manager.Goal Mr. Jones will complete and adhere to a monthly budgetto ensure that his basic needs are met for 6 monthswithout need for supplementation as monitored by self,staff report, and payee report by 10/00.Focus Area 5Care and management of medical and dental needs is complicated byMr. Jones’ difficulties in recognizing the need for intervention and infollowing through with medical recommendations due to Focus Area 1.Plan1. RN to schedule dental appointment and accompany Mr. Jones.2. RN to schedule appointment with family practitioner to addressmedical needs.Goal F/U re: esophageal reflux, non-TB mycobacterium, andsores on head/face.Goal dental appointmentGoal ongoing monitoringModule 12 28 Recovery and the Stress-vulnerability Training Basic Elements Frontline of Model Staff ACT

Notes to the facilitator and ACT leader:Prepare for Module 3:n Make copies of module 3, CoreProcesses of Assertive CommunityTreatment. Your copy is in thisworkbook; print copies for your teamfrom the CD-ROM.n Distribute the material to the teammembers who will participate in yourgroup session. Ask them to read thismodule before meeting as a group todiscuss it.n Make copies of these exercises:o Case Studies Discussion — 1o Case Studies Discussion — 2o Compare Assessment Procedureso Construct a Psychiatric/Social Functioning HistoryTimelineo Prepare for Your Weekly Consumer Scheduleo Complete a Weekly Consumer ScheduleConduct your third session:n When you convene your group, viewthe Core Processes of ACT on the PracticeDemonstration Video. Discuss the videoand the content of module 3.n One at a time, distribute the exercises to the groupand complete them.Consider this additional training activity:Food for discussion. After you complete theexercise, Compare Assessment Procedures, reviewyour agency’s new ACT assessment form with thegroup. Discuss what specific assessments eachdiscipline would be responsible for completingand the timeline for completing the assessment.but do not distribute them until your teammeets as a group. Again, your copies are on thenext pages; print copies for the team from theCD-ROM.Training Basic Recovery Elements Frontline and the of Staff Stress-vulnerability ACT Model 29 Module 12

Training Frontline StaffModule 3: Core Processes ofAssertive Community TreatmentModule 3 introduces you to the core processes of ACT, including the principles ofengaging consumers in treatment, how to conduct a comprehensive assessment, andthe tools that are specific to providing ACT services, such as the Psychiatric/SocialFunctioning History Timeline, the Weekly Consumer Schedule, and the Daily TeamSchedule. We discuss each process conceptually and administratively to help you seehow ACT teams function most effectively.Core processes of ACTn Compiling a thorough andcomprehensive assessment of theconsumer’s current and past psychiatricand social functioningn Constructing an historical timelinedepicting the consumer’s psychiatricand social functioning and priortreatment experiencesn Developing a treatment plan basedon needs and goals that the consumerarticulatesn Translating a consumer’s treatment planinto a schedule of day-to-day activitiesn Developing a daily schedule so teammembers can carry out the activitiesthat must occur that day.n Sharing the outcome of the previousday’s contacts with team membersn Conducting an ongoing assessment ofthe effectiveness of interventionsTraining Basic Recovery Core Processes Elements Frontline and the of ACT Staff Stress-vulnerability Model 1 Module 123

At first, you might think that the core processesare too time consuming and burdensome and thatyou will never be able to spare the time for them.That is simply not true. Effective teams that serveconsumers with very complex and demandingneeds follow these processes. In fact, it is part ofwhat makes them effective.Following the core processes will determinewhether your team is proactive or reactive. Youare beginning a long-term relationship withconsumers — which gives you the luxury of time.Take the time up front to really get to know them.To engage consumers in treatment, your team mustwork on goals that are important to the consumers.You also have the luxury of having team memberswho are equally responsible for consumers. If oneteam member needs to spend time with a consumerto gather assessment information, someone elseon the team can set time aside to obtain clinicalrecords. Most information for the comprehensiveassessment is collected while working withconsumers to meet their initial needs.In the long run, it is much more productive toinvest time up front getting to know consumers,forming sound detailed plans, and trackingthose plans closely than it is to grope along illinformedand unprepared. If your team doesnot invest resources to thoroughly sort out theexperiences consumers have had, does not learnwhat consumers hope to accomplish, and doesnot diligently monitor if goals are being met, yourteam will be managing crises rather than helpingconsumers progress.Psychosocial timelines, which monitor consumerprogress, help team members learn what has andhas not helped in the past. With the psychosocialtimeline, you translate the treatment plan intoa schedule of specific activities that become theschedule of contacts the team will have with theconsumer. Your team’s daily activities are basedon the schedule of activities developed for eachconsumer and any other appointments or situationsthat call for the team’s support.Here’s an overview of ACTprocessesn A consumer is referred to your ACT program.n The ACT leader and other staff who maypotentially work closely with the consumer meetwith the consumer to explain the program andassess the person’s initial needs.n Multiple team members meet with theconsumer as the work of meeting the consumer’sinitial needs begins. During these contacts,team members gather information for thecomprehensive assessment and timeline.n After 30 days, team members meet to poolinformation (to complete the comprehensiveassessment and timeline).n Based on the comprehensive assessment andtimeline, team members plan what they will do.This plan specifically includes what will be doneby whom, at what times, on what days.n A team member meets with the consumer toreview and achieve consensus about the plan.n The activities in the treatment plan are translatedinto a weekly schedule of contacts between theconsumer and the team.n Just before the team’s daily meeting, a designatedteam member checks the Weekly ConsumerSchedule for each consumer that the team serves.The team member writes each scheduled activityfor that day in the appropriate time slot. If aparticular team member is scheduled to carry outan activity, that person’s initials are written next tothe activity.n Next, the person who drafts the Daily TeamSchedule checks for appointments thatare not part of the regular activities on theWeekly Consumer Schedules. These might beappointments to apply for benefits, follow up on ajob lead, or look at an apartment that has becomeavailable — activities that the team providesModule 12 3 2 Recovery and the Stress-vulnerability Training Basic Core Processes Elements Frontline of Model Staff ACT

support for, but which do not recur. These arealso written on the Daily Team Schedule inthe appropriate time slot. If a particular teammember should attend the appointment, thatperson’s name is written next to the activity.n The person who drafts the schedule also checksfor crisis situations and consumers who arehospitalized. These are events that the teamwill respond to, but that are not part of the preplannedactivities or appointments.n The team begins going through itsCommunication Log. A team member calls outeach consumer’s name. When a name is called,anyone who had contact with that person inthe past 24 hours describes the contact andthe outcome briefly in behavioral terms. Bydoing this, the team is engaged in a processof continuously adding to the informationthey learned when doing the comprehensiveassessment and timeline and reassessing theeffectiveness of the consumer’s treatment plan.n During the daily team meeting, if team membersreport that a consumer is having a difficulty, theteam will strategize about how to address theproblem if it can be addressed quickly. If theproblem is more involved and requires extensivediscussion, the team will schedule a separatemeeting outside of the daily meeting.n Once all the scheduled activities, specialappointments, and any crisis response for thecurrent day have been noted, the team will makeany changes in the schedule that are neededto ensure that all the things that must happenthat day are taken care of. For example, as theconsumers are discussed, the team may decidethat a team member who was initially scheduledto meet with one consumer is needed moreurgently to intervene with another. Someone elsewill have to cover the original appointment.Engagement is a continuousprocessIt is important to understand the relationshipbetween the core ACT processes and engagingpeople in treatment. It is difficult, if not impossible,to engage someone in a treatment process in anymeaningful way unless the provider knows theconsumer’s needs and goals and, at the same time,also knows that what is being done focuses onreaching those goals.The engagement process never stops. If you wantpeople to stay engaged, you have to continue to helpthem progress in a way that is meaningful to them.It may take some consumers a while to realize thatyou are offering something different than they havereceived from the mental health system in the past.Ideally, engaging consumers in the process of ACTstarts before they are formally admitted to theprogram. Team members meet with consumers andtheir family members or other supporters, describethe program, find out the consumer’s immediateneeds and goals, and perhaps arrange for theconsumer to visit the program. Whenever you meetwith consumers, you learn more about the consumers’immediate needs and what their goals are.As members of your team begin to work withconsumers to meet their immediate needs,consumers are introduced to other members of theteam. For instance, if one consumer needs a placeto live, a team member might take that person tofind an apartment, but also might stop by the officeto introduce the person to the program receptionistand other team members. The next time the teammember meets with that consumer, someonefrom a different discipline might come along tobe introduced. That way, a new team member willbegin to get to know the consumer.Training Basic Recovery Core Processes Elements Frontline and the of ACT Staff Stress-vulnerability Model 3 Module 123

At times, consumers may be admitted to yourprogram while they are experiencing seriouspsychiatric symptoms. The consumers’ thinkingmay be very disorganized or they may beexperiencing delusions. In these instances, youmay have to move more slowly in introducing theconsumers to multiple members of the team sothat they are not overwhelmed. You will want todecide which team member will best help eachconsumer feel most comfortable and let that teammember initially be the primary contact. Until youhave established a degree of trust, you may want toinvolve other team members gradually.Assessments are comprehensive,not isolated interrogationsIn a more traditional assessment process, peoplefrom different specialties often sequentially“interrogate” consumers to elicit the informationthey need to complete assessment forms that arerelevant to their specialty. For example, nursesask about medical problems; social workers askabout benefits. Assessments seldom include anyobservations of consumers in their every dayenvironments, and they do not look at much outsideof the specific area being assessed.Although the information obtained by a practitionerfrom one discipline might be relevant to ACTteam members from other disciplines, ACT teammembers have to take the initiative to read all theassessments in the consumer’s chart. Even whenthey do read all the assessments, forms are often ina checklist format or use jargon and catch-phrasesthat convey very little about the unique impactof a particular problem on a specific consumer’slife or which factors in the environment may beexacerbating a problem.Sometimes assessment information is sharedat staffing or treatment planning meetings.Unfortunately, a practitioner from one disciplinemay have some information that seems irrelevant,not realizing that it fits with information thatanother team member has. These bits ofinformation must be shared so the whole picturefits together.In an ACT program, services are “made to order.”Before you know which services you will provide toa particular consumer and who will be involved indelivering them, you have to do a comprehensiveassessment. Unlike the traditional process, all theteam members who work with that consumer mustknow what was learned in each assessment.Learn about the comprehensiveassessment processThe comprehensive assessment is completedafter the team has had 30 days to get to know theconsumer. Individual team members are givenprimary responsibility for completing particularelements of the assessment.Table 4 gives you an overview of these elements,while Table 5 provides a more detailed profile.These are based on assessment forms includedin A Manual for ACT Start-Up (Allness &Knoedler, 2003).Module 12 3 4 Recovery and the Stress-vulnerability Training Basic Core Processes Elements Frontline of Model Staff ACT

Table 4. Principles of ACT AssessmentStart at the first meetingAddress immediateneeds firstAssess while you workBe sensitiveFocus on theconsumer’s needsShare what you knowLook for patternsThe assessment process begins during visits with consumers, family members, or other supporterswhile consumers are being admitted to the program.The initial assessment focuses on basic needs, such as safety, food, clothing, shelter, medical needs.As the team begins to meet those needs, other assessments are done. Most assessments are donewhile the team works with the consumer on problems that were identified in the initial assessment.The assessment process begins with the most critical problems and moves next to assessinginformation that is not particularly sensitive or personal. Then, as trust develops, more personalinformation is elicited (e.g., drug use, sexual activity).A critical part of the assessment is finding out what consumers’ preferences are and what they want toaccomplish.Assessments are not proprietary. (For example, medical assessment may be important to mental healthprofessionals; family assessment may be important to employment specialists.)Chronological information is collected in each area of assessment and then assembled in a timeline toshow the relationship between events and experiences in consumers’ lives.Table 5: Elements of a Comprehensive AssessmentPurposeWho isresponsible Sources of information TimeframeAssessment: Psychiatric history, mental status, and diagnosisn Ensure accuracy of diagnosisPsychiatristn ConsumerWithin 30 daysnInform plans that will be made withconsumer for treatmentn Familyn Supportersn Past treatment records aboutonset, precipitating events,course and effect of illnessFindings presented at daily meetings orto ACT leader and individual treatmentteam at the first treatment planningmeetingnPast treatment and treatmentresponsen Risk behaviorsn Current mental statusAssessment: Psychiatric history narrativeEstablish timeline of course of illness Psychiatrist n Psychiatrist’s interview withand treatment responseconsumern Psychiatric/Social FunctioningHistory TimelineStarted at admission or first interviewthe consumer has with psychiatrist.Completed within first 30 daysTraining Basic Recovery Core Processes Elements Frontline and the of ACT Staff Stress-vulnerability Model 5 Module 123

Table 5: Elements of a Comprehensive AssessmentPurposeWho isresponsible Sources of information TimeframeAssessment: Physical healthn Identify current medical conditions.Ensure proper treatment, follow-up,supportn Determine health risk factorsn Determine medical historyn Determine if there are problemscommunicating health concernsRegisterednursen Consumern Medical recordsFirst interview within 72 hours ofadmissionIf consumer is experiencing problemsconcentrating or needs time to get toknow staff to discuss sensitive areas, suchas sexual issues, assessment may need tobe completed over 2 to 3 interviewsPresented at first treatment planningmeeting unless immediate concernsexist, in which case nurse should consultteam psychiatrist and ACT leader andpresent those concerns at daily meetingAssessment: Use of drugs and alcoholn Determine if consumer currently hasa substance use disordern Determine if consumer has historyof substance abuse treatmentn Develop appropriate treatmentinterventions to be integrated intothe comprehensive treatment plann Establish chronologySubstance usespecialistn Composite InternationalDiagnostic Interview -Substance Abuse Module(CIDI-SAM) or similarstandardized instrumentn Consumer interviews ordiscussions conducted inhome or community settingsn Psychiatric History, MentalStatus, and DiagnosisAssessment and the HealthAssessmentn Past treatment providersAssessment begins at admissionIt may take several interviews to collectinformation since it is sensitive andrequires a sufficient level of rapport andtrust between consumer and mentalhealth professionalPresented at first treatment planningunless immediate concerns exist,in which case substance abusespecialist should consult ACT leader,psychiatrist, and individual treatmentteam and present information at dailyorganization staff meetingAssessment: Social development and functioningn Assess how illness interruptedor affected consumer’s socialdevelopmentn Information gathered about:n childhoodn early attachmentsn role in family of originMental healthprofessionaln Consumer interviewn Discussions conducted in homeor other community settingsBegins at admissionInformation may be gathered overseveral meetingsCompleted within 30 daysPresented at daily meeting, to ACTleader, or at the first treatment planningmeetingn adolescent and young adultsocial developmentn culture and religious beliefsn leisure activity and interestsn social skillsn involvement in legal systemn social and interpersonalissues appropriate forsupportive therapyModule 12 3 6 Recovery and the Stress-vulnerability Training Basic Core Processes Elements Frontline of Model Staff ACT

Table 5: Elements of a Comprehensive AssessmentPurposeAssessment: Activities of Daily Living (ADL)Who isresponsible Sources of information Timeframen Consumer’s current ability to meetbasic needsn Adequacy and safety of consumer’scurrent living situationn Current financial resourcesn Effect of symptoms on consumer’sability to maintain independentliving situationn Consumer’s individual preferencesn Level of assistance, support, andresources consumer needs to reestablishand maintain activities ofdaily livingMental healthprofessionaln Consumer interviewsn Discussions in home or othercommunity settingsn Interviewer must pay specialattention to consumer’spreferences and serve asconsumer’s advocate to ensureactivities of daily living andother services meet consumer’spreferencesInitial ADL plan completed at admissionto identify all immediate servicesconsumer may need (e.g., assists withnourishment, circumventing eviction)Information may be gathered overseveral interviewsComprehensive ADL assessmentcompleted within 30 daysPresented at daily meeting, to ACTleader, to individual treatment team, orat first treatment planning meetingAssessment: Education and employmentn How consumer is currentlystructuring timen Consumer’s current school oremployment statusn Consumer’s past school and workhistory (including military service)n Effect of symptoms on school andemploymentn Consumer’s vocational/educationalinterests and preferencesEmploymentspecialistn Consumer interviewsn School recordsn Past employersAssessment may be completed overseveral meetings, leading to ongoingemployment counseling relationshipbetween consumer and vocationalspecialistPresented at daily meetings, to ACTleader, team members working withconsumer, or at the first treatmentplanning meetingn Available supports for employment(e.g., transportation)n Source of incomen Education, military, and employmentchronologyAssessment: Family and relationshipsn Allows team to define with consumerthe contact or relationship ACT willhave with family or other supportersn Obtain information from consumer’sfamily or other supporters aboutconsumer’s mental illnessn Determine family’s or othersupporters’ level of understandingabout mental illnessn Learn family’s or other supporters’expectations of ACT servicesMental healthprofessionaln Consumern Family members or othersupportersBegun during the initial meeting withconsumer and family or other supportersparticipating in admissions processCompleted within 30 days of admissionPresented at the first treatment planningmeeting unless immediate concernsexist, in which case mental healthprofessional should consult teampsychiatrist and ACT leader and presentinformation at daily meetingsTraining Basic Recovery Core Processes Elements Frontline and the of ACT Staff Stress-vulnerability Model 7 Module 123

For the most part, assessments are carried outwhile team members are working with consumersaround their initial needs. Team members withvarious specialties may schedule a time to meetwith consumers to talk about issues related to thatspecialty. However, whenever anyone on the teamis with consumers, they are assessing:n symptoms,n the effect of those symptoms on everydayactivities,n the consumers’ strengths,n their preferences,n problems in the environment,n resources in the environment, andn whether a particular treatment, support, orservice the team is providing is serving itsintended purpose.Because of the extensive cross-training thatoccurs, team members look at things not onlyfrom the perspective of their own specialty, butthey also serve as the “eyes and ears” of otherspecialties. For instance, if the vocational specialistprovides transportation for the consumer to gogrocery shopping, the specialist could ask aboutemployment goals and past work experiences whilethey are together. During that trip, if the consumermentioned an interest in art, the vocationalspecialist could mention that interest during thenext daily meeting so that the team members whoare responsible for assessing the consumer’s leisureinterests could follow up. In addition, the team haslearned about an interest that the consumer mightuse for stress management.The goal of the comprehensive assessment is forteam members to understand consumers’ strengths,hopes, and experiences with mental illnessand mental health services. As you learn aboutconsumers, you share that information in “realtime” with your team. If you uncover potentiallyurgent needs — for instance, if you learn about acritical medical condition or an extremely unsafehousing situation — you would communicate thoseneeds immediately to the ACT leader.When all the assessments have been completed,the ACT leader or a designee takes the informationand compiles the comprehensive assessment. Thepeople who contributed to the assessment reviewit and discuss it as part of the initial treatmentplanning meeting. If team members later learnsomething about the consumer that is relevant tothe assessment, you would add that information tothe assessment.We suggest comparing your assessment forms tothe forms in A Manual for ACT Start-Up (Allness& Knoedler, 2003). to determine if any elementsare missing. If you find that elements of thiscomprehensive assessment are missing from yourassessment, you may want to consider creating asupplemental form or revising your forms. For asample Comprehensive Assessment, see module 2.Use a Psychiatric/SocialFunctioning History TimelineThe Psychiatric/Social Functioning HistoryTimeline is used to develop a detailed overviewof the significant events in consumers’ lives,consumers’ experience with mental illness, andtheir treatment history.Information for completing the timeline is obtainedonly with the consumer’s permission. You may needwritten releases to obtain some of the records thatare used to create the timeline. You should alsoget the consumer’s consent before you speak withfamily or employers.Module 12 3 8 Recovery and the Stress-vulnerability Training Basic Core Processes Elements Frontline of Model Staff ACT

Potential sources of information include:n past inpatient and outpatient records forpsychiatric and substance abuse treatment,including:❏ admission and discharge summaries,❏ physician orders,❏ treatment plans,❏ treatment plan reviews, and❏ assessments;n school records or transcripts;n medical treatment records;n arrest records;n interviews with the consumer;n interviews with family members orother supporters;n interviews with employers; andn interviews with past treatment providers.The timeline begins at the point a consumer firststarted experiencing problems relating to mentalillness and it continues to the present time. Afteryou initially complete the timeline, you may addmore information as it becomes available. You willreceive a copy of the timeline form with one of theexercises for this module.Steps for constructing timelinesStep 1 Carefully review the information gatheredabout the consumer to determinethe earliest date that the consumerexperienced problems with mentalillness. This is the beginning date for thetimeline. Write the date in the first blankspace under the column, Timeline Date.write the dates covered by each row inthe Timeline Dates column. For instance,if you determine that a consumer firstexperienced problems in September1975, and you decide to use a 1-year timeinterval, you would label the first rowunder Timeline Dates as September 1975to August 1976.You would label the next row September1976 to August 1977, etc., until thepresent. For the example in module 2,the final row would be labeled September1999 – the date the consumer wasadmitted to the ACT program.Step 3 After you identify the earliest dateand marked the time intervals coveredby each row in the Timeline Datecolumn, go back through your sourceinformation. By date, compile events,facts, and other information that maybe important on the timeline.Step 4 When you have noted all availableinformation on the timeline,answer these questions:n Is any information missing about aparticular period?n Does any of the information conflict?For example, do records show theconsumer was incarcerated andworking during the same period?n Have any treatments worked well inthe past?n Do any situations or events appear tohave contributed to the deterioration inthis consumer’s condition in the past?Step 2 Decide what increment of time will berepresented by each row in the timeline.This could be 1 or multiple months oryears. For instance, each row mightrepresent 1 month, 6 months, 1 year,2 years, etc.When the timeline is complete, it gives you apicture of how various events relate. It can help youcheck for gaps in the information you have about aconsumer’s life, and, if inaccuracies or conflictinginformation in clinical records exist, they willbecome apparent.After you decide on the time interval,Training Basic Recovery Core Processes Elements Frontline and the of ACT Staff Stress-vulnerability Model 9 Module 123

The timeline can be particularly useful in helpingyou see how various events in the consumer’s lifeare related. For instance, you will be able to see therelationship between:n various treatments and the consumer’s symptomsand functioning,n events that precede an increase in symptoms, andn when treatments that have initially been effectivebegin to break down.This information can be extremely valuable indeveloping a treatment plan.Create a treatment planACT team members will find that the treatmentplans that ACT teams develop tend to be dynamicand more intimately linked to services than thosedeveloped in more traditional settings. The dayto-daycontacts between team members andconsumers are taken directly from the treatmentplan. Every day the team reviews the contactsfrom the previous day. If the team’s activities aren’thelping consumers meet their goals or if new needsarise, the team can quickly modify the plans.Treatment plans define the specific issues andproblems that the team will address in both theshort-term (2-3 months) and long-term (6 months).The plans also detail what specific interventions orservices will be provided, by whom, when, for whatduration, and where the service will be provided.These plans are then translated into the WeeklyConsumer Schedule.Consumers’ perception of their needs and goals arean important part of treatment plans. If treatmentplans are not meaningful to the consumers youserve, consumers may let you know in direct orindirect ways. For example, you might notice thata consumer is never home when you go to visit orthat the consumer has more unscheduled afterhourcontacts.Changes in consumers’ responsiveness to the teamor changes in consumers’ level of symptoms orfunctioning should signal your team to ask:n What is the team (not the consumer)doing wrong?n Are we working on the consumer’s goal orour goals?n Are we respecting the consumer’s preferences?n Have the consumer’s goals changed?The team should formally review the treatmentplans every 6 months. However, you should revisethem immediately when consumers’ serviceneeds increase (e.g., symptoms return, heavy anddangerous use of substances occurs, an eviction ispending). On the other hand, when needs decrease(e.g., significant symptom remission, successfulintegration into a new job), the team should reviewthe plans with the consumers before you decreasesupport and services.Make a Weekly ConsumerScheduleAfter you write the treatment plan, translatethe goals into a weekly schedule of contacts andactivities that will occur between team membersand consumers.Each consumer has a weekly schedule that is filledout in pencil so it can be easily changed. Keepthese schedules in a central location and use themto complete the Daily Team Schedule. Some teamsuse a 5" x 8" card to represent a 1-week period.Others use a sheet of paper that has all the days inthe month on it.Module 12 3 10 Recovery and the Stress-vulnerability Training Basic Core Processes Elements Frontline of Model Staff ACT

How a weekly schedule might workPaula was recently admitted to your program. She hastwo children ages 5 and 7 and was reported to ChildProtective Services (CPS) for neglecting her children.She is at risk for having her children removed fromher care.No evidence exists that the children are in imminentdanger and Paula’s goal is to prevent her childrenfrom being taken from her. Team members facilitateda meeting between Paula and the CPS worker to helpPaula understand the specific concerns of CPS. Theyalso want to help Paula take specific steps to ensurethat the children are adequately cared for and toprevent them from being placed in CPS custody.After the meeting, the goals decided on were thatPaula had to:n consistently get her children up and ready forschool in the morning,n consistently provide an evening meal for thechildren (the school will provide breakfast andlunch), andn take care of basic housekeeping, like washingdishes and doing laundry.CPS also required that Paula attend parenting skillclasses 1 hour a week for 6 weeks; however, she saidthat it is difficult for her to listen to what the instructoris saying.Paula and the team agreed that a team member willcall in the evening to help her plan what clothes to layout for the morning and what materials the childrenneed to have ready for the next day.In the morning, a team member will call to:n make sure Paula is awake,n remind her to follow the routine she developed forgetting the children up,n check to see if any last-minute problems have occurred,andn offer positive reinforcement for her efforts to get herchildren to school on time.Team members will also provide transportation oncea week so Paula can buy groceries and they will assistwith meal planning. Transportation to parentingclasses is being provided by CPS, but the teamobtained a copy of the parenting curriculum and willmeet with Paula twice a week in her home to reviewand model the skills taught in the parenting class. Ateam member will also work with her twice a week tohelp her with laundry.Paula’s Weekly Consumer Schedule might look like theone in Table 6.Training Basic Recovery Core Processes Elements Frontline and the of ACT Staff Stress-vulnerability Model 11 Module 123

Table 6: Example of a Weekly Consumer Schedule Paula J.Monday Tuesday Wednesday Thursday Friday Saturday SundayAM 7:30phone callto promptmorningroutineSALLY7:30phone callto promptmorningroutineMARY7:30phone callto promptmorningroutineSALLY7:30phone callto promptmorningroutineSALLY7:30phone callto promptmorningroutineSALLY8:30laundrySALLY8:30laundrySALLY11:00mealplanning forthe week:grocerystoreMARYPM 7:00phone callto promptpreparationsfor themorningGEORGE7:00phone callto promptpreparationfor themorningGEORGE4:00visit to reinforce& modelparenting skillsSALLY7:00phone callto promptpreparations forthe morningGEORGE7:00phone callto promptpreparations forthe morningMARY4:00visit toreinforce& modelparentingskillsSALLY7:00phone callto promptpreparationsfor themorningMARYMake a Daily Team ScheduleEach day during the daily team meeting, have ateam member complete the Daily Team Schedule(Table 7). Many teams hold their meetings at 10:00a.m., thus allowing team members time to takecare of early morning contacts as they arrive at theoffice. If team meetings are at 10:00 a.m., the DailyTeam Schedule covers the contacts that occur from11:00 a.m. on the day of the meeting through 10:00a.m. the next day.The ACT leader goes through the WeeklyConsumer Schedule for each consumer and notesall the activities that are indicated for that day.Write these activities in the appropriate timeslot, along with the name of the person who isresponsible for the contact. Next, check for otherappointments that have been scheduled, such asdoctor visits, job interviews, appointments withSocial Security, or other meetings that are not partof the recurring schedule of contacts.Module 12 3 12 Recovery and the Stress-vulnerability Training Basic Core Processes Elements Frontline of Model Staff ACT

If you use a monthly calendar for consumers’schedule, note these types of appointments directlyon the consumer’s calendar. If you use a 5" x 8"card system, have separate calendars to note theseappointmentsIt is also likely that during the meeting teammembers may decide they need to contact aconsumer to follow up on something that anotherteam member mentioned. Also work these contactsinto the schedule.The ACT leader also checks a calendar on whichteam members note when they will be unavailableto see consumers, for instance, when a vacation isplanned, training is scheduled, or other disciplinespecificactivities are occurring. Also block off timefor charting and documentation.At the same time, the person developing theschedule should also listen for team membersto mention appointments that were made forconsumers. When these appointments arementioned, the scheduler should check to see thatthey are on the calendar.After noting the routinely scheduled contactsfrom the Weekly Consumer Schedules, specialappointments, and staff availability, draft a tentativeDaily Team Schedule. During the team meeting, ateam member might report a crisis that developedthe previous evening that requires an unscheduledvisit to a consumer. In that case, adjust the TeamSchedule to accommodate this visit.As soon as the meeting ends, the person who filledout the Daily Team Schedule should immediatelymake copies for everyone on the team. Keep yourcopy with you throughout the day. To protectconsumers’ confidentiality, use only consumers’initials on the Daily Team Schedule (See Table 7).Table 7: Example of a Daily Team ScheduleDate:On Call and Vehicle StatusList staff carrying beepers with beeper numbersList description of available vehiclesAM CallsList client’s name and reason for call8-10 In each time slot, list clients’ names, reason forcontact and name of responsible team member.Acute or hospitalized clientsList client’s name, status or locationPlanningList clients scheduled for initial orrevised treatment planning.2-310-11 3-511-12 5-712-1 7-91-2 PM CallsList client’s name and reason for callTraining Basic Recovery Core Processes Elements Frontline and the of ACT Staff Stress-vulnerability Model 13 Module 123

If your team covers an extensive geographicarea, when you develop the Daily TeamSchedule, also consider where team memberswill be throughout the day. Consider havingsomeone who is scheduled to be in a particulararea cover other contacts that need to be takencare of in that area on a particular day.However, if you use this approach, be careful tovary who covers different areas so that the programdoes not become a case management programwhere staff are assigned to a limited geographicarea and consumers are deprived of the benefit ofworking with multiple team members.Conduct a daily team meetingAt times, everyone on your team will be busyand you may be tempted to forego the daily teammeeting. Do not give in to this temptation. The dailyteam meeting is a vital activity for ACT programs.The daily team meeting is critical for ensuring opencommunication between team members. The dailymeeting is the place where all team members arekept current on what is happening with consumers.If a crisis is brewing, the team can talk about howbest to respond. Perhaps the team will decide totalk to the consumer about having someone visitmore often. If a consumer is having trouble gettingaccess to a resource, the team can quickly decideanother course of action. If a consumer is doingwell, team members can provide reinforcement.During the meeting, the ACT leader who isresponsible for the Communication Log statesthe first consumer’s name. Anyone who has hadcontact with that person in the last 24 hours brieflydescribes the purpose of that contact and whathappened. The person with the CommunicationLog writes a brief statement in the log.If a problem was noted during the contact and thatproblem can be dealt with by a quick suggestion,a team member might offer that suggestion. If amore complicated problem has arisen or if a morethorough discussion of the team’s response to asituation is needed, the team members who are theprimary contacts for the consumer might decide toschedule a review of the treatment plan.A focused team can move through a caseload ofapproximately 100 people in about 45 minutes.Hold other team meetingsIn addition to the daily team meeting to reviewconsumer progress, the team also meets oncea month to handle administrative issues andissues related to team development. During thismeeting, the ACT leader deals with administrativehousekeeping issues.Also during this time, the ACT leader sharesinformation about consumer outcomes andACT fidelity. (See Evaluating Your Program formore information.) This is also the time for teammembers to work on issues of team dynamics.The team meeting is structured around the DailyCommunication Log, a 3-ring binder that has anindex tab for each consumer, followed by severalsheets of notebook paper.Module 12 3 14 Recovery and the Stress-vulnerability Training Basic Core Processes Elements Frontline of Model Staff ACT

Exercise: Case Studies Discussion — 1HaroldHarold was a teacher who experienced his first episode of schizophrenia in his late thirties. He was wellknown in the community. During the course of his illness, Harold burned down two homes that he owned.He is tall and solidly built and his father was frightened by his temper on several occasions. His father didnot know what to do with him.Harold was ultimately sent to the State Hospital where he lived for several years. He had several passesduring his hospitalization, but a crisis occurred during each one. Even while taking medication, heexperiences severe paranoia and persecutory hallucinations. He was very much a loner.You visit him several times at the State Hospital in anticipation of his admission to your program. Hehas money from the sale of a home that he owned and could probably afford to buy a condo or rent anapartment in any of several modest neighborhoods. He has chosen, however, to move to an apartmentcomplex in a high-crime area.His father is at a loss because he does not know how to help him. He loves and cares for him, but is afraidof his temper. In the first few weeks that Harold is out of the hospital, he is victimized — his apartment isbroken into twice. When you call him, he does not answer the phone. When you go by his apartment, heyells at you to go away.Think about and describe how you might engage Harold in ACT.Training Basic Recovery Core Processes Elements Frontline and the of ACT Staff Stress-vulnerability Model 15 Module 123

How one team respondedHarold did not want a lot of help and he did not want a lot of company. We were delighted when he wouldopen the door just a crack when we went by to see him. Because of the paranoia Harold experienced, theteam decided that having a lot of different people going to his home might make Harold uncomfortable.We sent a nurse to visit regularly. She kept up her contact with Harold and introduced him to the doctorwho visited with Harold at his apartment. Harold agreed to letting the doctor continue to administer thepsychotropic injections he had received in the hospital. Occasionally, other team members would accompanythe nurse for a brief visit. We deliberately limited the number of people who had contact with him and lethim get familiar with us very slowly.Harold had no obvious desires. His father really loved him, but did not know what to do for him. Aftermonths, Harold agreed to have dinner with his father on Sundays. While talking with his father, we learnedthat Harold loved to play tennis as a child. By luck, a public court was near his home and we were ableto arrange for him to play tennis there with another consumer served by the team. Harold and the otherconsumer played tennis once a week for years.Module 12 3 16 Recovery and the Stress-vulnerability Training Basic Core Processes Elements Frontline of Model Staff ACT

Exercise: Case Studies Discussion — 2LucyLucy is a 54-year-old woman who has been referred to your program. She was acutely psychotic when shewas last seen.She has been picked up by the local police many times because of complaints from area residents. A typicalcomplaint would be someone in the community calling the police to complain about a woman camping intheir backyard or eating out of their garbage cans.She has moved from State to State for much of the last decade. You know the general area where she waslast seen. After weeks of looking for her, a member of your team locates her.Think about and describe how you might engage Lucy in treatment.Training Basic Recovery Core Processes Elements Frontline and the of ACT Staff Stress-vulnerability Model 17 Module 123

How one team respondedIt took us weeks to find Lucy. Once we found her, we just kept visiting and talking with her. I would go seeher and say, “Hey … this is Barbara. Is everything okay today?” or “Hey, this is Mary. She is a nurse. Is thereanything we can do to make you more comfortable?” We just would not give up hope.We continued our visits and, one day when we asked if she needed anything, she said, “My feet hurt.” Weoffered to bring her some shoes. “What size shoes do you wear?” we asked. The next time we visited her webrought her shoes.Each time after that we would bring her small treats and items to make her feel more comfortable. She sawthat we were not there to admit her to the hospital. We wanted to know what she needed and to help her.One day she asked, “Where’s my daughter? My daughter don’t talk to me any more.” We asked her if itwould be okay for us to call her daughter and she agreed. The daughter was apprehensive when we calledand did not want to “take on” her mother again. The daughter said she was burned out and had her ownfamily to care for.We met with her, described the program to her, and assured her that we would be responsible for hermother’s clinical care. After that, she agreed to go with us on a visit and we were able to get Lucy to comeout of the bushes she had been living in. Eventually, Lucy agreed to take medication. We were lucky becauseLucy is one of those people who responds well to medication.She found a good housing situation near her family. The team helped her keep up with her home, and shebegan to go to church, look up old friends, and crochet, which she loved. Lucy had been labeled one of themost difficult people in the city because of her extensive involvement with the police. Because we wereconsistent in visiting her and willing to go at her pace and respect her need to feel safe, Lucy experienced asuccessful outcome.Module 12 3 18 Recovery and the Stress-vulnerability Training Basic Core Processes Elements Frontline of Model Staff ACT

Exercise: Compare Assessment ProceduresSince it is important to become familiar with assessments related to other disciplines, first think about your owndiscipline, then we will share information from the disciplines of our team members so that we gain a full pictureof what we offer.List up to 5 things that are included in the assessments that members of your discipline typically complete.What is included in your discipline’s assessments?1.2.3.4.5.Now, let’s share our lists. Taking each specialtyrepresented on our team, list what is included inthat discipline’s assessment.Discipline ____________________________________Discipline ____________________________________1. 1.2. 2.3. 3.4. 4.5. 5.Discipline ____________________________________Discipline ____________________________________1. 1.2. 2.3. 3.4. 4.5. 5.Training Basic Recovery Core Processes Elements Frontline and the of ACT Staff Stress-vulnerability Model 19 Module 123

Discipline ____________________________________Discipline ____________________________________1. 1.2. 2.3. 3.4. 4.5. 5.Discipline ____________________________________Discipline ____________________________________1. 1.2. 2.3. 3.4. 4.5. 5.Are any items listed in another specialty area relevant to your specialty? What is it? How might it be relevant?How would you typically find out about this?If an item is listed under more than one specialty, what would you do with this information?Is it the same thing or something different?Module 12 3 20 Recovery and the Stress-vulnerability Training Basic Core Processes Elements Frontline of Model Staff ACT

Exercise: Construct a Psychiatric/Social Functioning History TimelineIf you were constructing a timeline about someone being admitted to your ACT program, a wide rangeof sources would go into making up the timeline. However, for the purposes of this exercise, use thecomprehensive assessment in module 2 (for Mr. Jones) to complete the timeline on the next page.This exercise will help you understand how to construct a timeline and how you can use it to check thethoroughness and accuracy of the information your team has about a consumer. You will also learn howyou can use a timeline to detect treatments and other circumstances that have and have not been helpfulto the consumer.Training Basic Recovery Core Processes Elements Frontline and the of ACT Staff Stress-vulnerability Model 21 Module 123

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Training Basic Recovery Core Processes Elements Frontline and the of ACT Staff Stress-vulnerability Model 23 Module 1 2 3Psychiatric/Social Functioning History TimelineClient name____________________________________________________________________________________TimelinedateAdmissionordischargedateInstitutionor providerPresentingproblem orlegal statusDiagnosis,symptoms,significantevents (suicideattempts,threats, violentacts, selfneglect)MedicationServicesrenderedReasons fordischargeLiving situation, dates,address or type, reason forleaving, Activities of DailyLiving (ADL)(Personal hygiene, householdactivities, housecleaning,cooking, grocery shopping,laundry, and financial sourceand money management)Page_________________________________Employment or education(Dates held, employerposition, type reasonfor leaving, othereducational activities)Other(Alcohol ordrug usetreatment, familyrelationshipsmedical other:specify)From: A Manual for ACT Start-Up, published by the National Alliance on Mental Illness. Deborah Allness & Bill Knoedler (NAMI). Copyright 2005.

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Exercise: Prepare for Your Weekly Consumer ScheduleUsing the completed treatment plan on the next pages (This is a copy of the one we used in module 2), listthe activities that need to happen to carry out the plan. Then check how often the activities are scheduled tooccur and note if any activities are scheduled on specific days (e.g., every Wednesday).Activities that must happen to carry out the planHow often those activities are scheduled to occurDaily Weekly Specific day? Monthly Othero o o oo o o oo o o oo o o oo o o oo o o oo o o oo o o oo o o oo o o oo o o oo o o oo o o oo o o oo o o oo o o oTraining Basic Recovery Core Processes Elements Frontline and the of ACT Staff Stress-vulnerability Model 25 Module 123

Module 12 3 26 Recovery and the Stress-vulnerability Training Basic Core Processes Elements Frontline of Model Staff ACT

ACT Treatment PlanPrimary treatment team: Sally S., Integration Specialist (IS)Fred F., Substance Abuse Specialist (SAS)Jane J., Employment Specialist (ES)Nancy N., Nurse (RN)Mike M., Psychiatrist (MD)Name: Mr. Jones SSN: 123-45-6789Tx Plan Date: 10/21/99Review Date: 4/21/99Discharge criterion:1. No significant major psychotic or affective symptoms for 2 years,and2. No major role dysfunction in areas of work, socialization, andself-care for 1 year under conditions of minimal treatment.DSM IV DiagnosesAxis I295.30 Schizophrenia, Paranoid Type304.80 Polysubstance DependenceAxis IVPsychosocial Stressors: Rejection by familyInadequate social supportUnemployedInadequate housing/unsafe neighborhoodMultiple arrests/convictionsHostile relationships w/othersSeverity:3 – ModerateAxis II301.7 Anitisocial Personality Disorder w/Borderline FeaturesAxis IIIHistory of exposure to Hepatitis A, B, & Cas validated by laboratory studies;Esophageal refluxNon-tuberculosis mycobacteriumAxis VCurrent GAF: 30Highest GAF past year: 30Strengths1. Survival skills developed while living on the streets2. High school diploma3. Desire for more stability in his life4. Engaging personalityFocus Area 1Jones’ experiences:1. persistent delusional thoughts of a religious, satanic, and paranoidtheme (i.e., “The County Sheriff’s Department injected me withgerm warfare.” “The devil is trying to kill me.”)2. persistent auditory hallucinations (Satan or the Holy Spirit aretalking to him) which, at times, command him to harm others orhimself (Mr. Jones has a history of suicide attempts and two felonyarrests for murder);3. periods of unpredictable agitation, leading to cursing with loudshouting speech and implicit threats to others;4. when acute, hallucinations and delusions increase with an increasein impulsive acts (often leading to misdemeanor arrests);5. symptoms become worse with the use of alcohol and illegalsubstances.Goal Trial of new-generation medication (Risperdal) to better controlpsychiatric symptoms while minimizing side effects. Mr. Joneswill take medications consistently as prescribed to allow for anadequate trial, or communicate a need for a change 90% ofthe time through 10/00 as measured by staff observation anddocument in progress notes.Goal Through 4/00, Mr. Jones will have no incidents of unplannedhospitalization as measured by staff, community, and crisisreport.Training Basic Recovery Core Processes Elements Frontline and the of ACT Staff Stress-vulnerability Model 27 Module 123

Plan1. MD to see every 4-6 weeks for medication prescriptions,symptom assessment, and supportive therapies;2. Daily 1:1 with IS for symptom assessment, medication education3. Weekly 1:1 with IS for psychoeducation, Sx assessment, anddevelopment of coping strategies (e.g., anger management,environmental issues); and4. ACT team to be available 24/7 for crisis response, support services.Focus Area 2History of involvement with the criminal justice system including3 felony convictions, multiple arrests, and hospitalizationsPlan1. IS to meet monthly with Mr. Jones for 1:1 on the relationshipbetween his mental health and behaviors and involvementin the criminal justice system and develop coping strategies.2. IS and SAS to interact with law enforcement officials to provideeducation about mental illness and function as liaison, as needed.Goal Through 10/00, Mr. Jones will have no arrests or physicalaltercations as measured by self, staff, community, andpolice reports.Goal Through 10/00, Mr. Jones will revisit his timeline on amonthly basis during1:1 to identify pattern and developpre-crisis coping strategies as monitored by staff report.Focus Area 3Extensive history of substance abuse which contributes to an increasein psychotic symptoms and possible suicidal/homicidal risk(see Focus Area 1). History of burglaries to obtain moneyto purchase substances (see Focus Area 2). Predominantly ETOHand “crack” cocaine use, but inclusive of LSD, PCP, MDMA,marijuana, amphetamines, tranquilizers, and sedatives. Mostrecent use was ETOH and “crack” cocaine. Substances are oftenused to “drown out the voices so I don’t have to hurt anyone.”Plan1. 1:1 motivational interview 3 x week – SAS2. Weekly dual-diagnosis group at ACT program office – SASGoal Mr. Jones will understand the connection betweensubstance use, increase in psychiatric symptoms, and arrestas evidenced by being able to verbalize the relationship tostaff on 3 or more different occasions prior to 4/00.Goal Mr. Jones will understand the dangers of combiningalcohol and other illegal substances with his prescribedpsychiatric medications as evidenced by being able toverbalize the dangers on 3 or more different occasionsprior to 4/00.Goal By 1/00, Mr. Jones will identify 1 or more factors hepersonally views as benefits from reducing or eliminatingthe use of alcohol or other substances.Focus Area 4Inability to conduct activities of daily living without consistent promptsand assists (i.e., living arrangements, money management, nutrition,housekeeping and grooming/hygiene) as directly related to Focus Area1 symptomatology, including paranoia, impulsive agitation, and poorinterpersonal social skills.Plan1. IS and SAS to work with Mr. Jones on locating affordable, safehousing.2. Weekly 1:1 with IS for apartment maintenance monitoring.(Based on need, interaction by staff will be titrated fromside-by-side assistance to verbal prompts.)3. IS to meet monthly with Mr. Jones to review budget andto liaison with his payee on as needed basis.4. Weekly monitoring of food supply/trips to grocery storeand education about nutritionGoal Mr. Jones will maintain his residence in a safe environmentfor 3 consecutive months by 10/00 as monitored by self,staff, and apartment manager.Goal Mr. Jones will complete and adhere to a monthly budgetto ensure that his basic needs are met for 6 monthswithout need for supplementation as monitored by self,staff report, and payee report by 10/00.Focus Area 5Care and management of medical and dental needs is complicated byMr. Jones’ difficulties in recognizing the need for intervention and infollowing through with medical recommendations due to Focus Area 1.Plan1. RN to schedule dental appointment and accompany Mr. Jones.2. RN to schedule appointment with family practitioner to addressmedical needs.Goal F/U re: esophageal reflux, non-TB mycobacterium, andsores on head/face.Goal dental appointmentGoal ongoing monitoringModule 12 3 28 Recovery and the Stress-vulnerability Training Basic Core Processes Elements Frontline of Model Staff ACT

Exercise: Complete a Weekly Consumer ScheduleTranslate your list of activities from the previous exercise onto the sample Weekly Consumer Schedule.Use this opportunity to point out strengths and weaknesses of the treatment plan. For instance, does thetreatment plan communicate the plan clearly enough so that other ACT team members can follow it?Sample Weekly Consumer ScheduleAMMonday Tuesday Wednesday Thursday Friday Saturday SundayPMTraining Basic Recovery Core Processes Elements Frontline and the of ACT Staff Stress-vulnerability Model 29 Module 123

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Notes to the facilitator and ACT leader:Prepare for Module 4:n Make copies of module 4, ServiceAreas of Assertive CommunityTreatment. Your copy is in thisworkbook; print copies for your teamfrom the CD-ROM.n Distribute the material to the team memberswho will participate in your group session. Askthem to read this module before meeting as agroup to discuss it.Consider this additional training activity:Integrate EBPs into comprehensiveservices: As a team, view theIntroductory Video from other EBP KITs.Discuss how your team will integratethe principles of those evidence-based practicesinto the comprehensive services you offer.Conduct your fourth session:n When you convene your group,view the Service Areas of ACT onthe Practice Demonstration Video.Discuss the video and the contentof module 4.n Distribute the criteria upon which the ACTprogram will be evaluated (fidelity and outcomemeasures) to review and discuss.Training Basic Recovery Core Processes Elements Frontline and the of ACT Staff Stress-vulnerability Model 31 Module 123

Training Frontline StaffModule 4: Service Areas ofAssertive Community TreatmentACT services include treatment, habilitation, and support. Module 4 discusses the rangeof services areas that team members provide to comprehensively meet the needs ofACT consumers, including:■ medication support,■ psychosocial treatment,■ community living skills,■ health promotion,■ family involvement,■ housing assistance, and■ employment.Services that you provide in these areas are not discrete, disconnected services,but rather are part of the larger, coordinated intervention of the team.Training Basic Recovery Core Service Processes Elements Areas Frontline and of the of ACT Staff Stress-vulnerability Model 1 Module 1234

Treatment, habilitation, andsupport: An overviewProviding services is not simply doing things forconsumers. Rather, the ACT team works closelywith consumers to teach them how to develop andcarry out strategies to reduce the negative effects oftheir mental illness and associated impairments incognitive and social functioning.This process includes overcoming problems thatresult from past experiences, as well as minimizingthe risk of further acute episodes of illness.The services that ACT teams deliver are notdiscrete, disconnected services, but rather parts ofan integrated intervention. Services provided byACT teams target problems and address objectivesin multiple areas of consumers’ lives (see Table 8).Table 8: ACT Service ComponentsMedication support Psychosocial treatment Community living skillsn Educate about medicationsn Order medications from pharmacyn Deliver medications to consumersn Organize medicationsn Monitor adherence and side effectsn Monitor use of medicationsn Take a problem-oriented approachto counseling/psychotherapyn Manage illnessn Maintain crisis intervention —Be available 24/7n Treat co-occurring disordersn Coordinate care (e.g., hospital withcommunity)n Practice good hygienen Follow proper nutritionn Buy and care for clothingn Use transportationn Keep housen Manage moneyn Enjoy social relationships andleisure activitiesHealth promotion Family involvement Housing assistancen Conduct preventive health educationn Ensure medical screeningn Schedule health maintenance visitsn Act as liaison for acute medical caren Assess need for reproductivecounselingEmploymentn Provide support in finding workn Act as liaison with employers andeducate employersn Serve as job coachn Support employmentn Manage crisesn Provide family psychoeducationn Actively engage family members inconsumers’ recoveryn Find suitable sheltern Support housing onceestablishedn Develop relationship withlandlordModule 12 34 2 Recovery and the Stress-vulnerability Training Basic Core Service Processes Elements Frontline Areas of Model StaffACT

Medication supportMedications are one of the important toolsthat consumers use to reduce or eliminate thesymptoms of mental illness that make it difficultfor them to handle everyday activities or engage inmajor life roles. Medications may also help prolongthe period between episodes of illness.Not all people who are diagnosed with a psychiatricdisorder benefit to the same extent frommedications. Some will decide they do not want totake them.If consumers decide not to take medications, yourteam should continue to work with them in otherareas. If consumers are considering discontinuingmedications, it may be helpful to talk to them aboutwhat happened before when they stopped takingmedications. Help them plan ahead of time what theywould like to have happen if their symptoms worsen.If consumers’ symptoms are exacerbated when nottaking medications, team members can work withthem to assess the relationship between not takingmedications and experiencing acute psychiatricsymptoms. You should also weigh the relativecosts of taking medications instead of experiencingsymptoms.Educate consumers and familiesabout medicationsEducate consumers and families about howmedications work and their roles in treatingsymptoms. Remember that education occursover time in both verbal and written forms and inlanguage geared to consumers and families.Order medications from pharmacySometimes people have more prescriptions to fillthan their insurance will cover. Team members maybe able to work with local pharmacies to arrange forconsumers to get 2 months’ worth of a prescriptionat once to stagger the task of ordering medications.You can also work with pharmacies about packagingpills so that they are easier to take.Deliver medications to consumersWhen consumers have difficulty taking medicationsas prescribed, having a team member visit theirapartment to give medications to them can beextremely helpful. This contact may be very brief orcan also offer a chance to check about other needs.For some consumers, telephone calls are sufficientto monitor medication.Organize medicationsWhen multiple medications are prescribed, itcan be difficult for consumers to take the properdoses at the right time. The team psychiatristcan help by simplifying medication regimens,by prescribing the fewest medications takenthe least number of times to effectively controlsymptoms with minimal side effects.Until a simplified regimen has been worked out,team members can help consumers organizetheir medications in special containers that holdindividual doses.Training Basic Recovery Core Service Processes Elements Areas Frontline and of the of ACT Staff Stress-vulnerability Model 3 Module 1234

Monitor medical complianceand side effectsSome consumers may not wish to take medicationsbecause of their side effects. Team members shouldcarefully monitor medication adherence and sideeffects and facilitate communication betweenconsumers and the team psychiatrist so thatmedications can be adjusted quickly when needed.You will also need to work closely with consumersand the team psychiatrist to develop strategies tohelp consumers relieve minor side effects.Psychosocial treatment:A problem-oriented approachto counseling/psychotherapyCounseling/psychotherapy in ACT follows aproblem-oriented and supportive approach,integrated into the continuous work of all teammembers who contact consumers. Consumers’goals as laid out in the treatment plan are the focusand, thus, are an integral part of the treatment,habilitation, and support that the team provides.Manage IllnessTeaching illness management and recovery skillsis a method of systematically helping consumersrecognize the symptoms of mental illness that theyexperience and using strategies that they chooseand rehearse to minimize the effects of thosesymptoms.It also includes teaching consumers to recognizefactors that trigger episodes of symptoms and todevelop and practice specific steps to prevent theseepisodes. Problem-solving, goal-setting, and stressmanagement skills are integral parts of illnessmanagement.We recommend formal training with the IllnessManagement and Recovery KIT for one or moreteam members.Crisis intervention: Be available 24/7ACT teams can respond in various ways toacute situations and may be able to prevent theneed for consumers to be hospitalized. Whenconsumers have acute needs, your team mustquickly assess the situation and devise ashort-term treatment plan.This plan usually addresses:n ensuring the safety and protection of theconsumer or others,n providing emotional support,n structuring the consumer’s time and activity,n treating specific symptoms (e.g.,pharmacological),n evaluating symptoms in a controlled environment,n providing relief from demands and stress,n detoxifying the consumer, andn evaluating and treating coexisting medicalproblems.In responding to these needs, your team might:n increase the frequency of contact with theconsumer,n arrange for others in the consumer’s supportsystem to provide support and supervision,n change medications to treat symptoms anddistress,n manipulate the environment to limit stressors,n lessen work and social demands through directintervention with employers and others, andn limit substance use that exacerbates or causesthe situation, such as providing more frequentsupports and prompts or arranging a temporarychange of residence.Module 12 34 4 Recovery and the Stress-vulnerability Training Basic Core Service Processes Elements Frontline Areas of Model StaffACT

If your ACT team is available around the clock, youwill be able to quickly respond to a crisis. Knowingthat the team will see or talk with consumerswhenever it is necessary reassures consumers andfamily members.Crisis visits are more frequent in the early stagesof involvement in ACT. Once it is clear that suchsupport is forthcoming, the number of crisesusually diminishes and can often be handled bytelephone.Integrated treatment forco-occurring disordersRather than sending consumers with co-occurringsubstance abuse problems to a separate programfor substance abuse treatment, the ACT teamdelivers both individual and group interventionstargeting substance abuse. When a consumer issuspected or known to have a substance abuse ordependency disorder, assign one of your team’ssubstance abuse specialists to work with thatperson. Although the substance abuse specialist hasprimary responsibility for assessing the consumer’ssubstance use disorder and planning treatment,the substance abuse specialist will collaborateextensively with other team members in carryingout these interventions.Using outside providers for substance abusetreatment is highly selective. An instance where anoutside provider might be used is for detoxificationor when residential services are warranted.When you do use outside services, your teamwill refer consumers to those programs thatare adapted specifically to consumers withco-occurring disorders.We recommend formal training with the IntegratedTreatment for Co-Occurring Disorders KIT for oneor more team members.Acute psychiatric hospitalizationSince ACT teams can quickly respond tochanges in a consumer’s status and increase thenumber of contacts to address problems, ACTservices often reduce hospitalizations. However,sometimes inpatient care is appropriate.A Manual for ACT Start-Up (Allness & Knoedler,2003) suggests that short-term psychiatric inpatienttreatment may be appropriate for consumers who:n are suicidal or homicidal or their behavior isof such intensity that they are likely to commita suicidal or homicidal act soon and the riskcannot be immediately reduced through ACTcrisis interventions;n are experiencing symptoms (e.g., confusion,disorganized thinking) that are causing seriousneglect of self-care and risk of physical harm andthe risk cannot be immediately reduced throughACT crisis interventions;n are experiencing mixed acute symptoms ofmental illness and drug intoxication such thatintensive, supervised medical care is required toreduce the effect of the substance abuse so thatacute symptoms of mental illness can subside;n need medication changes or adjustment and,because of concern for significant medicalcomplications, side effects, or exacerbation ofsymptoms during this change, need the safety andsupervision of an inpatient unit;n require medical workups or medical treatmentfor serious conditions (e.g., bacterial pneumonia,poorly controlled diabetes), when thenecessary medical procedures and treatmentscan reasonably be completed only on aninpatient basis; andn present severe symptoms when the team alreadyhas a large number of acute and subacuteconsumers who require very intensive servicesand the team therefore cannot responsiblyprovide services in the community for anotherconsumer with high needs.Training Basic Recovery Core Service Processes Elements Areas Frontline and of the of ACT Staff Stress-vulnerability Model 5 Module 1234

According to A Manual for ACT Start-Up (Allness& Knoedler, 2003), longer term hospitalization isappropriate for consumers who have such severesymptoms and accompanying poor functioningthat they are often at risk of harm to others orthemselves or cannot carry out basic survivaltasks (e.g., nutrition, shelter, clothing, healthcare,protections from harm) despite intense dailyteam efforts and repeated short-term psychiatrichospitalizations over an extended period of time.When consumers are in the hospital, your ACTteam is still responsible for care. This means thatyou must make certain that the inpatient staff havecritical information for treatment needs. Whenconsumers are admitted to an inpatient setting,your team’s role is to make the transition fromoutpatient to inpatient status, and back again, assmooth as possible and to facilitate collaborationbetween the team and the inpatient staff.Collaborating with inpatient staff facilitatesthe rapid development of a treatment plan andprovides continuity in treatment to the greatestextent possible.Admitting consumers to the unitAt times, consumers will seek emergencyadmissions on their own or they may be takento the hospital by family, emergency personnel,or the police. But in most cases, your ACT teamwill usually initiate inpatient admissions.When your team is involved in the admissionprocess, you can provide emotional support toconsumers. You can share information with theinpatient staff to help them understand consumers’history and current status and to create a smoothertransition between outpatient and inpatient care.It is difficult to admit consumers unless funding forthe hospitalization is ensured ahead of time, thoughin true emergencies, hospitalization will proceedeven if funding is not guaranteed. When consumershave insurance (e.g., Medicare or Medicaid),funding may not be a problem, though increasingly,payors require preadmission and concurrent review.When preadmission assessment is required, staffmust usually present information and negotiatewith a screening or gatekeeper agency that hasauthority to provide funding. When this agency isclosely managing local funding and using very tightcriteria for hospitalization, this negotiation can be adifficult process that demands patience and skill.After the funding for the admission has beenapproved, a team member should call the attendingpsychiatrist of the inpatient unit to requestadmission and explain the details of the case. Youshould then inform a nurse on the unit.When the inpatient unit has approved theadmission, the team member should:n accompany the consumer to the unit,n help him or her through the admission process,n assist the inpatient staff in establishingcommunication with the consumer, andn settle the consumer into the unit.You should bring a copy of the current treatmentplan and a list of current medications with dosagesand side effects.Key tasks during hospitalizationYour team should stay actively involved withconsumers who are hospitalized. Someone on theteam who has worked closely with the consumershould visit the consumer at least once a day(assuming geography permits) to:n assess the consumer’s status and progress,n implement parts of the treatment plan(with the agreement of the inpatient staff),n make recommendations to the inpatient staff, andn provide support and advocacy for the consumer.Module 12 34 6 Recovery and the Stress-vulnerability Training Basic Core Service Processes Elements Frontline Areas of Model StaffACT

When your team works with hospitalizedconsumers and inpatient staff, follow these practicalrules of conduct:n Tell the staff of your presence on the unit, askthem about the consumer’s status, and tell themthe purpose for your visit. Introduce yourself tostaff that you do not know.n After seeing the consumer, communicate anynoteworthy information to the inpatient staff(e.g., whether the consumer seems to be indistress, is losing control, or needs monitoringand support).n Respectfully suggest changes that the inpatientstaff can make in their approach with theconsumer (e.g., avoid giving detailed informationand direction to a consumer who processesinformation poorly).n Monitor medication side effects with theconsumer. You may also present yourobservations to the team’s psychiatrist sothat person can use these observations whileconferring with the inpatient psychiatrist.n Model interpersonal approaches to the consumerthat your team has found helpful in the past(e.g., being supportive to a consumer who isfeeling irritable or hostile, eliciting informationabout psychotic symptoms from a nondisclosiveconsumer, or being directive with an anxious andscattered consumer).The team psychiatrist should regularly (i.e., once ortwice a week) confer with the inpatient psychiatristto relay his or her and other team members’observations and recommendations.Most inpatient units organize their collectiveobservations and formulate treatment plans forconsumers in staffing meetings. Usually, they holdan initial staff meeting within the first few days ofadmission, with others scheduled as needed or atregular intervals. Consumers often attend part ofthe meeting. Your team staff should respectfullybut assertively ask to be involved in these meetings,starting with the first one soon after admission.Inpatient staff are usually quite receptive to thisinvolvement and will learn to plan and rely on it.Most consumers will usually remain continuouslyon the inpatient unit over the first 1 to 2 days afterthey are admitted to allow staff to assess and treatpresenting symptoms. After that, it is useful formost consumers (unless they are suicidal or veryeasily distressed) to continue to be involved withtheir life and treatment in the community, even ona daily basis.When they are not clinically counter-indicated,passes for consumers to visit the community mightbe part of the overall treatment plan that youdevelop with the inpatient staff. While they arestill in the hospital, passes allow consumers to stayinvolved in:n normal activities (e.g., handling tasks like payingbills or returning to work);n social and supportive relationships (e.g., visitingfamily and friends, staying in contact with theteam); andn personally satisfying activities (e.g., going for awalk, shopping).Overnight or weekend passes provide a method forconsumers and your team to assess improvementand readiness for discharge.Planning for discharge andreturn to the communitySome consumers will be hospitalized for onlya short time and will need very little change inthe treatment plan that guides your ACT team’sinterventions in anticipation of discharge.In other cases, however, markedly differentinterventions may be needed at discharge. Youcan use passes to test new interventions beforeconsumers are discharged.Training Basic Recovery Core Service Processes Elements Areas Frontline and of the of ACT Staff Stress-vulnerability Model 7 Module 1234

Long-term hospitalizationSome consumers will require long-term (i.e., threemonths or more) hospitalization. These admissionsare usually involuntary and are preceded by anappropriate legal process. Continuity of care (i.e.,continued team participation) is as important forthese consumers as it is for consumers who arehospitalized on acute units.Typically, your team would initiate the legal or otherproceedings leading to the commitment, usuallyafter an extended period of unsuccessful treatmentin the community. Relying heavily on the strengthof the team, team members should approachconsumers who were hospitalized long-term withthe same commitment, energy, and communityorientation as they do any other consumer.At the same time, they must support and assist theinpatient staff to provide optimal treatment. Thismeans visiting consumers at least weekly to assessprogress and status, developing treatment plansin collaboration with the inpatient staff, attendingregular staff meetings, and involving consumers inregular treatment and rehabilitation activities in thecommunity as part of the treatment plan (i.e., work,socialization, etc.).Discharge planning should be underway longbefore discharge. Outpatient treatment andrehabilitation activities should have been anongoing part of the treatment plan and areincreased in intensity as consumers movecloser to discharge. In fact, readiness isdetermined by consumers’ ability to handleincreased expectations in the community.You may have to secure necessary resources(particularly housing) and introduce theconsumer to them (e.g., overnights, extendedvisits). The outpatient plan is usually an intenseand structured one. It anticipates the need fordaily contact, including:n supervision,n medication management,n self-care,n housing support,n financial management or support,n socialization, andn other activities.Community living skillsPracticing good hygiene, maintaining propernutrition, buying and caring for clothing, and usingtransportation are community skills that you mustapproach with the same sensitivity as other foci onskills development or redevelopment.When consumers request a change in any of theseareas, take a direct approach to work on them.When such goals are clearly incorporated in thetreatment plan and agreed to by the consumer, youhave a basis to address them.Other consumers may be unaware of problems inany of these areas and may not want to change.Limited performance may be related to stigmaabout mental illness or personal issues.You may have to tie work on community living skillsinto related goals expressed by the consumer. Forexample, a consumer who is interested in workingmay understand that good hygiene and reasonableattire are necessary to obtain and keep a job. Aconsumer who is interested in a specific socialactivity may accept that good nutrition is necessaryto have the energy to engage in activities. Aconsumer who is interested in living independentlymay realize that housekeeping is necessary to keepan apartment. Team members can help with relatedactivities (such as shopping for groceries or clothes,and apartment cleaning), encouragement, andreminders.Module 12 34 8 Recovery and the Stress-vulnerability Training Basic Core Service Processes Elements Frontline Areas of Model StaffACT

The goals of community living skills are to:n guarantee that consumers’ basic needs are beingmet;n continually assess consumers’ Activities of DailyLiving (ADL) functioning to ensure they get thehelp needed to live with quality in communitysettings;n help consumers upgrade their quality of life(e.g., move to nicer living arrangements, increasepossessions); andn provide ongoing ADL services which meetconsumers’ needs and preferences so that theycan manage ADL functions as autonomously aspossible.HousekeepingYou must respect consumers’ housekeepingstyle and preferences — just imagine your teammembers coming into your home and imposingtheir standards and methods on you.However, some minimal level of housekeeping isnecessary to ensure basic hygiene, such as puttingfood away, washing dishes, taking the trash out,etc. There is also the practical aspect of organizingthings to make them easier to find. Finally,housekeeping rituals can help bring a sense ofstructure to a consumer’s day and a degree of orderto the environment.If consumers need help organizing and planninghousekeeping tasks, team members might workwith them to define a list of tasks. It is worth theeffort to discuss how often the task will be done.For example, should the consumer make the bedevery morning, some time during the day, moreoften than not, or when the mood strikes? Shouldconsumers wash dishes when no more clean onesare available, before going to bed, or immediatelyafter meals? Does washing dishes include dryingand putting them away? This level of detail isparticularly important because multiple peoplework with consumers and the plans must beconsistent to avoid confusion.Whatever decisions are made, the team must makecertain that consumers have basic information (i.e.,which day the trash is picked up, which dumpsterthe trash is put into) and the equipment or tools(trash bags, dish soap, broom) needed.Money managementSome consumers will manage their own moneybut may need assistance from the team in otherways. For example, they may need help setting upa checking account, developing a system for payingbills on time, or obtaining entitlements (usuallyinvolving going with the consumer to apply forbenefits and assisting with documentation andcompleting forms).For other consumers, the team may help preventthem from being taken advantage of financially(e.g., mail or TV scams) or advocate for them toobtain a release from such commitments.ACT has the capacity to directly handle consumerfunds to promptly pay monthly bills and distributecash (e.g., for groceries, laundry, spending) inamounts determined by each consumer’s budget. Thepurpose of this system is to help consumers managemoney and to give them frequent access to cash whenbudgeting or financial management is a problem.For example, if a consumer’s monthly spendingmoney is gone in the first week of the month,the consumer suffers high stress, which iscounterproductive to treatment. The team shouldwork with the consumer to devise a plan to allocatethe spending money. The team would hold thespending money and take responsibility to set upsmaller amounts of money that the consumer receivesmore frequently (e.g., daily, three times a week).The program may manage consumer servicesmoney and individual consumer funds includingdisability benefit payments, such as SupplementalSecurity Income (SSI) and Social SecurityDisability Insurance (SSDI), under the supervisionof a payee or financial guardian.Training Basic Recovery Core Service Processes Elements Areas Frontline and of the of ACT Staff Stress-vulnerability Model 9 Module 1234

Consumer services moneyConsumer services money are funds allocatedin the ACT program budget to provide directfinancial grants or loans to consumers whendisability benefits have not started, a benefitscheck is delayed, or the first check from a newjob is insufficient to cover expenses. Lack ofimmediate financial resources keeps manyconsumers on inpatient units longer than theirpsychiatric treatment requires and contributes tohomelessness.Consumer services money can also be used foremergencies, rent, security deposits, food, clothing,recreation, and transportation costs. Your ACTleader will inform you if a consumer service fund isavailable for your ACT program.Individual consumer fundsIndividual consumer funds consist of entitlements(e.g., SSI, SSDI, and VA pensions and benefits),consumer wages, grants, and family supports. Whenconsumers have a protective payee appointed bySocial Security or a financial guardian designatedby the court, the team works with the consumersand the financial guardian or protective payee tomake sure that the beneficiaries’ day-to-day needsare met and that records are kept to show how themoney was used.The ACT leader and the program assistant maymanage and operate a system (in compliance withSocial Security requirements) to:n dispense money to consumers from individualconsumer accounts according to the consumers’monthly budget,n maintain an account with a local bank for depositsand withdrawals of consumer money,n document all cash transactions with receiptsthat consumers sign when they receive cash andreturn these receipts to the payee or guardian todocument that consumers’ received the moneyor keep the receipts to document payment ofconsumer services money,n communicate regularly with financial guardiansand protective payees of consumers to coordinateindividual consumer budgets between theprogram and the guardian or payee, andn receive money from guardians or payees andmaintain records of receipt and current balancesfor each consumer.Interpersonal relationships andsocial activitiesThe onset of mental illness can interfere with socialdevelopment. It may impede consumers’ ability toform relationships, get and give emotional support,and relate as adults with families, employers, andlandlords.Module 12 34 10 Recovery and the Stress-vulnerability Training Basic Core Service Processes Elements Frontline Areas of Model StaffACT

The ACT team provides a broad array of services tohelp consumers:n develop, restore, and maintain social andinterpersonal relationships,n engage in social and leisure-time activities, andn develop their social network.According to A Manual for ACT Start-Up (Allness& Knoedler, 2003), the nature and quality of aconsumer’s social and sexual relationships beforethe onset of illness, such as social involvement withfriends from adolescence through early adulthood,whether the consumer dated, had relationships, ormarried, is often correlated with social competence.Consumers who achieved milestones beforebecoming ill will generally be more sociallycompetent than those who did not since they havebeen exposed to these adult life experiences. Thisis what being socially competent means – to meetadult interpersonal goals.Social skills, on the other hand, refer to consumers’ability to relate interpersonally. Consumers oftenlack social skills because of the symptoms of mentalillness, the effects of institutionalization, or the lackof learning opportunities during childhood andadolescence.The following two case examples model how ACTteams may support consumers in developing ormaintaining relationships:JeromeMarciaJerome developed social skills before the onsetof mental illness when he was 20 years old andattending a community college. He was a goodstudent, played sports, and had friendships in highschool.His mental illness is episodic with almost completerecovery between episodes. He has been able tore-establish his relationships because treatmentwas provided immediately to lessen symptoms andcontinuously to minimize and prevent recurrent acuteepisodes.The team provides treatment and support to Jeromeduring episodes and the periods of recovery afterthe episodes. The team then provides rehabilitationservices long term to help him re-establish orrenegotiate the relationships that have beendisrupted by these episodes, as well as to initiate newfriendships and social relationships. For example, theteam met with Jerome and his longtime friends androommate to provide support for Jerome to talk aboutand resolve issues that resulted between them duringthe last episode.The team provided both ongoing supportive therapyand side-by-side assistance to help reinvolve Jeromein existing relationships and to pursue leisure-timeactivities.This treatment and rehabilitation process is continuousas Jerome experiences fluctuations in his symptoms.Marcia has few social skills. Her only interpersonalrelationships are with her family. The onset of hermental illness occurred gradually in her middle to lateteens, disrupting her normal social development andproducing impairments in social functioning.She has had great difficulty making a full recoverybetween episodes because of persistent symptoms andfunctional difficulties. Additionally, it was traumatic forTraining Basic Recovery Core Service Processes Elements Areas Frontline and of the of ACT Staff Stress-vulnerability Model 11 Module 1234

her and her family when acute episodes disrupted herparticipation in high school formative relationships;normal family functioning was also altered becauseof her symptoms and impairments and because ofher involvement in mental health services. (Psychiatrichospitals can be frightening and stigmatizing placesfor young people and their families.)Marcia experiences significant social anxiety, iswithdrawn, and has idiosyncratic characteristics in herdress (e.g., at all times wearing a red bandanna overher hair).She needs significant long-term help from the team toimprove her social competence and skills, pursue andestablish a social niche with one or two relationshipswith others (e.g., other people, consumers, volunteers,and family), and participate consistently in leisuretimeactivities.The team provides a combination of social stimulationand involvement for Marcia through one-to-oneactivities with staff (e.g., social recreation contacts)and groups (e.g. social recreation activities) to pursueconsistent and regular leisure-time activities. The teamalso provides gradual teaching of social skills (e.g.,“small talk” and assertiveness) to increase her socialcompetence and comfort.Services to restore interpersonalrelationshipsServices to help consumers restore interpersonalrelationships include:n assessing consumers’ social and interpersonalfunctioning, social development, culture, socialskills, and interests;n developing individualized plans withrehabilitation interventions to establish,reestablish, and maintain relationships andincrease social skills and comfort in socialsituations;n receiving individualized services in normal socialsituations (e.g., a neighborhood coffee shop, thebreak room at work) in the community in whichconsumers normally interact with people;n identifying and overcoming stressors,behaviors, and environmental issues whichaffect and diminish the quality of interpersonalrelationships;n reducing the stress of unstructured time –evening, weekends, and holidays – and fosteringnormal social routines; andn planning, participating in, and handling holidays,family, and other social obligations with less stressand greater competence.Service featuresIdentifying consumer goalsThe team’s activities to enhance consumers’ socialand interpersonal relationships and enjoymentare individualized to the needs and goals of eachconsumer. For example, before a holiday, the teamreviews plans with consumers and helps them workout how they will spend that day. If they usuallyspend the holiday with family, the plan may includehelping them call the family to make arrangements.In addition, the team will problem-solve andprovide side-by-side coaching and assistance to helpconsumers determine how long to visit, the bestmeans of transportation, what to wear, and howto manage interpersonal interactions with family.Team members may meet with consumers andtheir family before the holiday to problem-solveand plan ways to make it an enjoyable time for all.The team works out how to establish anunderstanding and trusting relationship witheach consumer and then provides it. Eachteam member plays an important role for eachconsumer — as an unwavering social supportand a role model who maintains the appropriatebalance between professional, interpersonalboundaries and adequate compassionatesupport. This modeling occurs in all contactsbetween consumers and team members.Module 12 34 12 Recovery and the Stress-vulnerability Training Basic Core Service Processes Elements Frontline Areas of Model StaffACT

Interpersonal support is offered to consumers overtime in a gradual, step-by-step fashion. Continuousservices allow consumers the time to restore socialfunctioning. Consumers may delay having tofunction in some social situations until they feelbetter. Continuous interpersonal support allowsconsumers to practice social skills in real-life socialsituations during their recovery.Restoring social relationshipsThe team and the consumer evaluate therelationships in consumers’ lives that have beenaffected or disrupted by mental illness. Togetherthey develop and implement strategies to reconcileor renegotiate these relationships. The stigma ofmental illness and lack of help from traditionalservice providers in this area, often preventsconsumers from directly dealing with disruptionsin interpersonal relationships.Through problem-solving, role-playing,and modeling, consumers make goals andplan approaches to reconcile or renegotiaterelationships. Intervention may also include teammembers working with consumers and friendsor family members in an intermediary role,or supporting consumers in meeting with theindividual to either get closure or re-establish therelationship on mutual terms.To help consumers make their relationships moresymmetrical, the team directly helps consumersmove from the receiving position in relationships tothat of an equal participant (e.g., giving and taking).This is accomplished through cognitive-behavioralapproaches, including assertiveness training and allone-to-one rehabilitation services provided by teammembers, such as:n redirecting a question to the consumer that thelandlord directed to the team member,n drawing the consumer into a social conversation,n practicing before an interaction with an employerhow the consumer prefers to respond toanticipated feedback, andn helping a consumer to shop for a present to havesomething to take to a parent’s birthday party.Promote healthAll consumers need access to high-qualitypreventive and health maintenance care. Someconsumers who receive ACT services have serioushealth concerns. You will find consumers with HIV,hepatitis, diabetes, and any number of significanthealth problems. One of the challenges for theteam, especially when consumers experienceacute psychiatric symptoms, is to keep a pulse onconsumers’ medical conditions, and their responseto treatment for those conditions.Restoring balance in relationshipsHelping consumers restore a sense of personalwell-being can be difficult because mentalillness has rendered them so vulnerable andhighly dependent on services just to survive. Theasymmetrical quality of helping relationships,especially if help is provided in a patronizing orauthoritarian manner, can cause consumers tofeel controlled and demoralized.Provide preventive health educationGood basic health practices – daily hygiene,adequate food, proper rest – can make it easier forpeople to deal with stressors. The problem is thatpsychiatric symptoms and associated impairmentsdirectly and indirectly create challenges to goodbasic health practices.Training Basic Recovery Core Service Processes Elements Areas Frontline and of the of ACT Staff Stress-vulnerability Model 13 Module 1234

One indirect challenge is that many consumershave limited incomes. Supplies for daily hygienelike soap, shampoo, and toothpaste can be a luxurywhen income is extremely limited.If available, you can buy hygiene items withconsumer services funds; however, you should beable to find community agencies that will donatethese items. The team should monitor daily hygienesince marked changes may signal a change inconsumers’ clinical status.The team also needs to monitor whether consumersare getting proper rest. As with changes in hygiene,changes in sleeping patterns can also indicatea change in symptoms. Alternately, difficultygoing to sleep as well as difficulty staying awakemay indicate the need to adjust the consumer’smedication regimen.Along with encouraging good basic health practices,the team also provides education on preventingcertain communicable diseases, including HIVand sexually transmitted diseases. This educationis particularly important for consumers who areengaged in high-risk behaviors.Psychiatric medications and medications prescribedfor physical illnesses can interact in ways that alterthe effects of the medication or can lead to serioushealth problems. Consumers must be educatedabout the medications they are taking and possibleinteractions. The team psychiatrist might alsocommunicate directly with medical providers (withconsumers’ permission) to work out medicationregimens that safely address both consumers’mental health and physical health needs.Arrange medical screeningScreening for medical concerns begins during theinitial intake. The team makes certain that anyhealth needs that have been identified are followedup, such as:n eye exams and opticians, if needed;n periodic testing for HIV, which is essential forpeople with risk factors; andn mammograms for women according to ageguidelines.This task might involve helping consumersschedule appointments with their medical provider,providing transportation, and even helpingconsumers practice explaining their health concernto medical providers.Schedule health maintenance visitsIdentifying a regular primary care provider is oftenfirst; ensuring regular follow-up comes next. Dentalneeds are often neglected and require attention.Serve as a liaison for acute medical careAcute medical care refers to emergency orinpatient medical treatment. Consumers may beanxious about a medical crisis or about being in amedical environment. ACT team members mayoffer additional support. Similar to the supportoffered during a psychiatric hospital admission, theteam should:n provide interpersonal support,n ensure financial coverage,n facilitate admissions,n communicate with medical providers,n ensure that consumers understand andcommunicate their choices, andn facilitate discharge after care.Module 12 34 14 Recovery and the Stress-vulnerability Training Basic Core Service Processes Elements Frontline Areas of Model StaffACT

Provide reproductive counselingConsumers vary in how much they know aboutsafe sex practices and birth control. It is importantto assess whether or not consumers say they aresexually active. Team nurses, or other well informedstaff, should counsel consumers on the approachesto birth control.When a pregnancy occurs, team involvementis usually very important. The team must adaptconsumers’ psychiatric treatment so that it meetsthe needs of the pregnancy and delivery. The teammust ensure that consumers receive prenatal careand maintain communication with hospital staffboth during and after delivery.Involve familiesHistorically, consumers have received most of theirsupport and care in the community from familymembers, particularly parents and siblings. Thesefamily responsibilities have, in fact, grown in recentyears with decreased hospitalization and increasedemphasis on outpatient treatment.Since families provide significant amounts of careand support, family roles can become distorted. Forexample, a mother’s role may become intertwinedwith that of nurse or social worker. When a familymember has a serious mental illness, it can bedifficult for a family to just be a family.On the other hand, some consumers have little orno contact with their family and may say they havenone. It is a tragedy when consumers have beenseparated from parents, brothers, sisters, or otherfamily because of their mental illness. It is also aserious shortcoming when practitioners assume thatfamilies want nothing to do with consumers withoutmaking an effort to find out if this is really the case.At the point of admission, ACT team membersshould ask consumers for permission to involvefamily or other supporters in their treatment.Relationships between families and consumersmay have been damaged during the course ofthe illness. The family may hesitate to becomeinvolved. In such cases, the team, with theconsumer’s consent, tries to contact familymembers to obtain and give information.Attempts are made to help families graduallyreconnect in a way that respects the distancethey have established. When relatives becomeaware of the consumer’s improvements and theteam’s comprehensive service delivery, they oftenreconsider and wish to have more contact.Initiating the collaboration process involves:n meeting with consumers and family membersto learn about consumers’ developmentaland illness history, current symptoms,functional status, and the consumer-familyrelationship (e.g., typical ways of copingwith and helping consumers, relationshipstresses, conflicts, and family strengths);n presenting basic information about theACT model and developing an initial planthat specifies what the team, consumer,and family member will do; andn scheduling subsequent meetings and phonecalls to exchange information and ideas.Family meetings can occur at consumers’homes, the family home, or the ACT office.Family meetings usually involve consumers, butthey can choose not to attend. The psychiatristparticipates in most meetings with familymembers and is readily available to assist themwith crises and other problem-causing situations.Training Basic Recovery Core Service Processes Elements Areas Frontline and of the of ACT Staff Stress-vulnerability Model 15 Module 1234

Provide ongoing family supportand psychoeducationACT team members should maintain routinecontact with families and other supporters. Opencommunication with families often prevents crisesand minimizes the likelihood that families and ACTteam members work at cross purposes.Routine contact may include ongoing educationabout mental illness (i.e., etiology, symptoms,functional problems, course, and treatment). Whennecessary, the team may help families learn newattitudes toward themselves and the consumer,such as not blaming themselves or being overlycritical of the consumer.We recommend formal training using the FamilyPsychoeducation KIT for one or more teammembers.Lessen consumers’ over-reliance on familySoon after admission, the team uses a practicalproblem-solving approach to assess consumers’reliance on the family and the stress this may haveproduced for both consumers and family members.ACT teams use two approaches to reduce theresponsibility of the family:n First, team members take over many practicalfunctions (e.g., shopping, laundry, moneymanagement) that family members perform.They then help consumers to carry out thesetasks on their own.n Second, since teams can easily increasethe intensity of the contacts they have withconsumers, they can even provide intensivesupport to help consumers gradually move out ofthe family home into their own residences if thisis a consumer goal.Manage crisesWhen the family is actively engaged with the ACTteam, family members are likely to take advantageof the 24/7 availability for crisis intervention. Talkwith the family about their experience with types ofcrises that arise and how they have previously beenhandled. Such information can be used to develop aplan if similar crises should arise.Assist consumers with childrenAs many as one-third of women consumers givebirth to children both before and after developingmental illness. Unfortunately, mental illness cancompromise their ability to parent. The needs ofconsumer parents are complex and demand thatthe team alter services to address both the needs ofthe parent and children.The team helps consumers with the range ofactivities related to pregnancy and parenting,including:n arranging prenatal, physical, and practical care;n soliciting and using appropriate social servicesagencies;n facilitating admission to the hospital and effectivecommunication with hospital staff during thebirth process and immediate neonatal period;n supporting neonatal, infant, and childhoodparenting at home;n changing psychiatric treatment, particularlypsychotropic medications, to match the needs ofpregnancy and delivery; andn educating the consumer about birth control.Module 12 34 16 Recovery and the Stress-vulnerability Training Basic Core Service Processes Elements Frontline Areas of Model StaffACT

All activities involve partners and other peopleparticipating in the consumers’ support network.The team also supports consumers in fulfillingparenting responsibilities and coordinatingservices for the child. Though the team’s primaryobligation is to consumers, the team works withconsumers to help them meet parenting roles andresponsibilities. The team does not directly providephysical or psychological care for children, buthelps consumers and their families plan for andobtain necessary services (e.g., parenting training,child care, respite care) for them.Team members help consumers relate to thesystems (e.g., schools, social services, mental healthprofessions) that provide services to childrenby being available to meet with the agencies,consumers, and children and by reviewing agencyrecommendations with consumers and establishingplans to carry them out. Over time, staff oftenfunction as extended family and friends toconsumers and their children.Another role of the ACT team is supporting themother-child relationship for single parents.A single woman consumer often has difficultyeffectively and safely raising her child. Even withintensive assistance by the team, other familymembers, and social services agencies, consumermothers are sometimes forced to surrender thisresponsibility to others (e.g., family members,foster parents, adoptive parents). Sometimesthis happens voluntarily. At other times, despiteher protests, the mother is forced by the courtto relinquish custody. This is a painful situationfor the consumer, who suffers a great lossand a blow to self-esteem and confidence.Though the welfare of the child is primary, theteam supports the mother’s desire and need tomaintain a connection with her child. Where thisis not harmful to the child and is potentially to thechild’s benefit, the team advocates with the courtand social services for the consumer’s continuedcontact and a visitation plan. The plan may includesupervised visits with team members, familymembers, or social services staff.When the consumer is doing poorly or not adheringto the treatment, the team is responsible to reportthis to social services, which may lead to suspensionof visits. Some consumers learn to ask staff orothers to help with their child during roughtimes, even to the point of suggesting that theyhave more limited contact with their childrenuntil they feel better.Assist with housingThe type of housing consumers live in may beinfluenced by their financial situation. The teamcan provide support 24 hours a day if needed fora person to live independently, but being able toafford safe, independent housing is a challenge tobe addressed. Being knowledgeable about publichousing is a first step. Since the public housingenvironment may not be safe or manageablefor ACT consumers, it is important to identifysubsidized housing (especially Section 8) options.Many consumers have very limited incomes(e.g., SSI, SSDI, wages from part-time work).Consumer services funds from the ACT programbudget are often needed to cover many upfrontcosts for housing (i.e., security deposits, firstmonth’s rent, etc.).In addition to the financial barriers to obtainingsafe affordable housing that people encounter,some people served by the ACT program willrun into difficulty because they have a poorrental history with multiple evictions,poor credit, or criminal records.It is very important for team members to get toknow people in the community who own or managelow-cost and subsidized housing and to introducethem to the program. People may be willing totake risks on consumers with marginal rental orcredit histories if they know that the ACT programis providing support around payment of rent andmonitoring upkeep of the residence.Training Basic Recovery Core Service Processes Elements Areas Frontline and of the of ACT Staff Stress-vulnerability Model 17 Module 1234

Find suitable shelterAllness & Knoedler suggest that working withconsumers to find housing begins by meeting withconsumers to learn about their housing needs andhousing history (Allness & Knoedler, 2003):n Where has the consumer been living?n How often has the person moved?n What did the person like and dislike about pastsituations?n What type of living situation does the consumerwant and need?Team members schedule regular appointmentswith each consumer to plan and look for a place tolive. Consumers are involved in every step of theprocess including:n discussing important considerations in choosinghousing:❏ security deposit;❏ rent;❏ utilities;❏ accessibility to transportation, laundry, stores;❏ safety; and❏ personal preferences.n looking for leads in the paper or by contactingproperty owners that the team or consumerknows;n driving by to check out the location of rentals;n coaching and rehearsing with consumers how tobest present themselves on the phone or in faceto-facecontacts with property owners;n accompanying the consumer to meet thelandlord, if appropriate and necessary; andn securing leases and ensuring that the consumerpays the rent.Help with shared housingTo make housing costs more affordable, someconsumers may share an apartment or house. Sinceliving with another person who may have differenthabits and preferences can be difficult, the teamshould help consumers who are sharing housing todevelop skills and routines to solve the problemsthat may arise. The team should facilitate meetingsbetween potential roommates to help them clarifypractical issues such as:n how they will split the rent and utilities,n how they will handle cooking and cleaning, andn what their preferences are for social activities.The team may want to discourage situations wheremore than 2 or 3 consumers share a dwellingbecause several consumers living together maytake on the attributes of a group home rather thanindependent housing.Monitor safetyDespite your most creative and diligent effortsto help consumers obtain safe housing, someconsumers will live in housing that is in questionablerepair or they will live in areas of relatively highlevels of crime. When it comes to the safety ofthe property, your team must be prepared to helpconsumers hold property owners to meeting atleast minimum legal standards for safe housing.For instance, gas should not leak from appliances,electric wiring should not be exposed, toilets shouldflush, floors should not have holes in them, andfaucets should turn on and off. If needed, municipalauthorities may be able to help you pressureproperty owners to bring housing up to code.Module 12 34 18 Recovery and the Stress-vulnerability Training Basic Core Service Processes Elements Frontline Areas of Model StaffACT

In some instances, consumers will live in areas inwhich drug activity and other types of crime areabundant. Consumers can be easy prey for peoplewho are looking for a place to sell drugs or forsomeone to carry drugs for them. Consumers mayalso be easy marks for people who would hustlethem out of their money or personal property.A secure, locked building and regular phone orface-to-face support and coaching might helpconsumers in not permitting entry to those whomight take advantage of them. Your local lawenforcement agency may also provide tips for crimeprevention. You will want to take advantage oftraining opportunities and work with consumers ondeveloping and practicing specific things they cando to protect themselves and their property.The more difficult situation is when consumersare using drugs and have contact with peoplewho are selling drugs. In such instances, part ofthe substance use treatment plan might includechanging residence or involving the consumer inalternative activities.Help with consumers’ landlordand neighborsSometimes landlords and neighbors may be anxiousabout renting to or living near someone with aserious mental illness. This may have nothing todo with anything that the consumer does. It maysimply come from stereotyped misperceptionsabout people with mental illness.It may help if consumers make an effort to getto know their landlord and neighbors and evenmention that they have an illness as a way ofeducating people about what mental illness is reallylike. Consumers might also choose to have landlordsor neighbors meet members of the team and givethem information about how to contact the team.Help purchase and repair household itemsConsumers may need help buying householditems at reasonable prices. They may also needsome instruction for performing simple repairs(unclogging a sink) or how to get help if the powergoes out or telephone is disconnected.EmploymentACT supports consumers’ goals for obtainingcompetitive employment. As Allness and Knoedlerdescribe it, the:“focus is on promoting growth rather thanstability (even for those individuals with seriousimpairments) and maximizing normalizationrather than minimizing stress.”(Allness & Knoedler, 2003)The team’s employment specialists are responsiblefor providing the majority of employment services.They are also responsible for directing and teachingother team members to participate in carrying outindividual consumer employment plans.Provide support in finding workInitially, consumers may indicate that they do notwant to work or that they are unable to work. Inaddition, because staff cannot predict how wellpeople are going to do on the job, they may hesitateto help consumers find jobs. To overcome bothconsumer and staff apprehension, it is critical forthe employment specialist and all team members towork together to encourage, support, and provideconsumers with work opportunities.Training Basic Recovery Core Service Processes Elements Areas Frontline and of the of ACT Staff Stress-vulnerability Model 19 Module 1234

Promote consumer interest andmotivation to work by:n talking about work, stimulating thinking aboutwork, and raising expectations to work;n offering formal and informal interactions withworking consumers to help them realize that theycan work;n determining consumers’ work interests andcompetencies; andn finding work opportunities for consumers toboost their confidence.Direct placement in competitive jobsExperience with ACT has demonstrated thatconsumers can work competitively if they receivesufficient help to get a job and continued supportto retain it. ACT employment services are basedon the Evidence-Based Practice SupportedEmployment model in which the employmentspecialist works directly with individual consumersto find competitive work in the community asquickly as possible.Job opportunities are matched with consumerpreferences and skills. Consumers rarely lose jobsbecause they do not have the skills for the job.More often, they lose jobs because mental illnessand related symptoms and behavior affect jobperformance.For this reason, the assessment process includesa careful review not only of consumers’ educationand past work experience, but also of thespecific behaviors or other issues that have beenproblematic on the job. Consumers are matchedwith jobs that play into their strengths.Serve as a liaison with employersand educate themOne of the first tasks of an employment specialistis to identify opportunities for consumers in theemployment market. To do so involves meetingwith potential employers to understand theiremployment needs and ensuring availability of theACT team for consultation and support.To make an appropriate job and consumer match,the employment specialist, with other teammembers, uses the want ads, friends, personalcontacts, and the yellow pages to find jobs. Forsome consumers, employment specialists mayencourage employers to create jobs that fit both aparticular consumer’s needs and goals with those ofthe work setting.Provide ongoing supportEmployment specialists provide ongoingsupport to help consumers and employerssolve any problems that arise on the job.Employment specialists also assist consumersin transitioning to a new job, as needed.After gaining work experience (e.g., working atseveral jobs) consumers often begin to:n gain confidence that they can maintain a job,n successfully meet expectations that go with work,andn feel a sense of accomplishment and belonging.We recommend formal training with the SupportedEmployment KIT for one or more team members.Module 12 34 20 Recovery and the Stress-vulnerability Training Basic Core Service Processes Elements Frontline Areas of Model StaffACT

DHHS Publication No. SMA-08-4344Printed 200821768.0708.7765020404