The foundations of the working alliance in assertive community treatment teams
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ABSTRACT: Background
In this study, we aimed to identify and define the fundamental components of the working alliance in multidisciplinary (Flexible) Assertive Community Treatment teams with shared caseloads, in order to support their daily practice and further research. Methods
After reviewing the literature, concept mapping with professionals and clients was used to define the working alliance in (F) ACT teams. The resulting concept maps formed the basis for the working alliance assessment instrument, which was pilot tested with professionals and clients through cognitive interviews with a think-aloud procedure. Results
The study led to the development of a twenty five-item assessment instrument to evaluate working alliances in multidisciplinary teams (WAM) that was comprised of three subscales: bond, task/goal and team. Two different versions were developed for clients and professionals. Conclusions
The WAM instrument was developed to determine the quality of the working alliance in (F) ACT teams. Future research will focus on testing its psychometric properties and predictive value. Supplementary Information
The online version contains supplementary material available at 10.1186/s12888-021-03563-x.
SUBMITTER: van Haaren M
PROVIDER: S-EPMC8582115 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Aims and method The impact of flexible assertive community treatment (FACT) has been observed in people previously supported by assertive community treatment (ACT) teams, but its effect on those previously with a community mental health team (CMHT) has not been studied in the UK. An observational study was conducted of 380 people from 3 CMHTs and 95 people from an ACT team, all with a history of psychosis, following service reconfiguration to 3 FACT teams. Results People previously with a CMHT required less time in hospital when the FACT model was introduced. A smaller reduction was observed in people coming from the ACT team. Both groups required less crisis resolution home treatment (CRHT) team input. Clinical implications FACT may be a better model than standard CMHT care for people with a history of psychosis, as a result of reduced need for acute (CRHT and in-patient) services.
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Project description:During the past decades deinstitutionalisation policies have led to a transition from inpatient towards community mental health care. Many European countries implement Assertive Community Treatment (ACT) as an alternative for inpatient care for "difficult to reach" children and adolescents with severe mental illness. ACT is a well-organized low-threshold treatment modality; patients are actively approached in their own environment, and efforts are undertaken to strengthen the patient's motivation for treatment. The assumption is that ACT may help to avoid psychiatric hospital admissions, enhance cost-effectiveness, stimulate social participation and support, and reduce stigma. ACT has been extensively investigated in adults with severe mental illness and various reviews support its effectiveness in this patient group. However, to date there is no review available regarding the effectiveness of youth-ACT. It is unknown whether youth-ACT is as effective as it is in adults. This review aims to assess the effects of youth-ACT on severity of psychiatric symptoms, general functioning, and psychiatric hospital admissions.A systematic literature search was conducted in PubMed, Cochrane Library, PsychINFO and CINAHL published up to March 2017. To assess methodological quality of the included studies, the Oxford Centre of Evidence-Based Medicine grading system was used.Thirteen studies were included in this review. There are indications that youth-ACT is effective in reducing severity of psychiatric symptoms, improving general functioning, and reducing duration and frequency of psychiatric hospital admissions.The current literature on youth-ACT is limited but promising. There are indications that youth-ACT is effective in reducing severity of psychiatric symptoms, improving general functioning, and reducing duration and frequency of psychiatric hospital admissions. The effect of youth-ACT may be comparable with the effect of ACT in adults. Similar as in adult ACT, the studies on youth-ACT found effects that vary from small to large. Randomized experimental research designs are needed to further corroborate effectiveness.
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Project description:ObjectiveForensic assertive community treatment (FACT) is an adaptation of the assertive community treatment model and is designed to serve justice-involved adults with serious mental illness. This study compared the effectiveness of a standardized FACT model and enhanced treatment as usual in reducing jail and hospital use and in promoting engagement in outpatient mental health services.MethodsSeventy adults with psychotic disorders who were arrested for misdemeanor crimes and who were eligible for conditional discharge were recruited from the Monroe County, New York, court system. Participants were randomly assigned to receive either FACT (N=35) or enhanced treatment as usual (N=35) for one year. Criminal justice and mental health service utilization outcomes were measured by using state and county databases.ResultsForty-nine participants (70%) completed the full one-year intervention period. Nineteen (27%) were removed early by judicial order, one was removed by county health authorities, and one died of a medical illness. Intent-to-treat analysis for all 70 participants showed that those receiving the FACT intervention had fewer mean±SD convictions (.4±.7 versus .9±1.3, p=.023), fewer mean days in jail (21.5±25.9 versus 43.5±59.2, p=.025), fewer mean days in the hospital (4.4±15.1 versus 23.8±64.2, p=.025), and more mean days in outpatient mental health treatment (305.5±92.1 versus 169.4±139.6, p<.001) compared with participants who received treatment as usual.ConclusionsThe Rochester FACT model was associated with fewer convictions for new crimes, less time in jail and hospitals, and more time in outpatient treatment among justice-involved adults with psychotic disorders compared with treatment as usual.
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Project description:ObjectiveTo assess, during a period of decreasing psychiatric inpatient utilization, cost savings from Assertive Community Treatment (ACT) programs for individuals with severe mental illnesses.Data sourceU.S. Department of Veterans Affairs' (VA) national administrative data for entrants into ACT programs.Study designAn observational study of the effects of ACT enrollment on mental health inpatient utilization and costs in the first 12 months following enrollment. ACT enrollees (N = 2010) were propensity score matched to ACT-eligible non-enrollees (N = 4020). An instrumental variables generalized linear regression approach was used to estimate enrollment effects.ResultsInstrumental variables estimates indicate that between FY2001 and FY2004, entry into ACT resulted in a net increase of $4529 in VA costs. Trends in inpatient use among ACT program entrants suggest this effect remained stable after FY2004. However, eligibility for ACT declined 37 percent, because fewer patients met an eligibility standard based on high prior psychiatric inpatient use.ConclusionsSavings from ACT programs depend on new enrollees' intensity of psychiatric inpatient utilization prior to entering the ACT program. Although a program eligibility standard based on prior psychiatric inpatient use helped to sustain the savings from VA ACT programs, over time, it also resulted in an unintended narrowing of program eligibility.
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Project description:The working alliance may be relevant in unguided smartphone-based interventions, but no validated measure exists. We evaluated the psychometric properties of the six-item Digital Working Alliance Inventory (DWAI) using a cross-sectional survey of meditation app users (n = 290) and the intervention arm of a randomized trial testing a smartphone-based meditation app (n = 314). Exploratory factor analysis suggested a single-factor solution which was replicated using longitudinal confirmatory factor analysis. The DWAI showed adequate internal consistency and test-retest reliability. Discriminant validity was supported by a lack of association with social desirability, psychological distress, and preference for a waitlist condition. Convergent validity was supported by positive associations with perceived app effectiveness and preference for an app condition. Supporting predictive validity, DWAI scores positively predicted self-reported and objective app utilization. When assessed at Weeks 3 or 4 of the intervention, but not earlier, DWAI scores predicted pre-post reductions in psychological distress.
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Project description:BackgroundIt has been shown that positive treatment expectancy (TE) and good working alliance increase psychotherapeutic success in adult patients, either directly or mediated by other common treatment factors like collaboration. However, the effects of TE in psychotherapy with children, adolescents and their caregivers are mostly unknown. Due to characteristics of the disorder such as avoidant behavior, common factors may be especially important in evidence-based treatment of posttraumatic stress symptoms (PTSS), e.g. for the initiation of exposure based techniques.MethodsTE, collaboration, working alliance and PTSS were assessed in 65 children and adolescents (age M = 12.5; SD = 2.9) and their caregivers. Patients' and caregivers' TE were assessed before initiation of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). Patients' and caregivers' working alliance, as well as patients' collaboration were assessed at mid-treatment, patients' PTSS at pre- and post-treatment. Path analysis tested both direct and indirect effects (by collaboration and working alliance) of pre-treatment TE on post-treatment PTSS, and on PTSS difference scores.ResultsPatients' or caregivers' TE did not directly predict PTSS after TF-CBT. Post-treatment PTSS was not predicted by patients' or caregivers' TE via patients' collaboration or patients' or caregivers' working alliance. Caregivers' working alliance with therapists significantly contributed to the reduction of PTSS in children and adolescents (post-treatment PTSS: β = - 0.553; p < 0.001; PTSS difference score: β = 0.335; p = 0.031).ConclusionsTE seems less important than caregivers' working alliance in TF-CBT for decreasing PTSS. Future studies should assess TE and working alliance repeatedly during treatment and from different perspectives to understand their effects on outcome. The inclusion of a supportive caregiver and the formation of a good relationship between therapists and caregivers can be regarded as essential for treatment success in children and adolescents with PTSS.
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