Category: Treatment - DBT
Flexible Assertive Community Treatment (FACT) teams merge Assertive Community Treatment (ACT) and Intensive Case Management (ICM) services to address the unmet service needs of individuals with complex mental health difficulties who may not meet strict ACT eligibility criteria, but require ACT-level care during acute episodes of illness (Sood et al., 2017). Specifically, ACT teams typically give preference to patients with psychotic illnesses and bipolar disorder, while other severely mentally ill (SMI) patients with complex health and social needs including those with primary substance use disorders, intellectual disabilities, and personality disorders may be refused services. In order to serve a wider range of SMI patients and develop more integrated, flexible services, a high fidelity inner city ACT team was redesigned based on FACT principles. Given that the FACT model includes a psychologist, who plays a central role in patient treatment and staff training, there was a unique opportunity to deliver evidence-based psychological treatments to patients who are not typically seen in more traditional outpatient settings. After providing a brief description of this treatment model and the range of patients it can serve, the case example of “Andrea” is presented using a single-case reversal design. Andrea was a 33-year-old female with intellectual disability, a longstanding history of depression, and significant difficulty with emotion regulation resulting in frequent use of emergency room (ER) services. During the initial baseline stage in the one year prior to joining the FACT team, Andrea had 44 ER visits and 1 inpatient admission for mental health-related concerns, primarily suicidal ideation and self-harm behaviors (e.g., overdose, cutting herself), despite receiving standard psychiatric care in an outpatient setting. Once admitted to this more intensive community team Andrea began to meet weekly with the team psychologist for adapted dialectical behavior therapy (DBT), including skills training, chain analyses of problematic behaviors, behavioral contingency management, and 24-hour access to skills coaching by case managers on the team, most of whom do not have formal DBT training. During her first year of treatment with the team, her use of ER services reduced to seven visits, only two of which were in the ladder six months of the year. During the return to baseline phase, Andrea continued to receive services from her FACT team, but the DBT components of her treatment were terminated for a one-year period during which the team psychologist was on a temporary leave. During this one-year period, Andrea’s ER visits increased again to 19 visits, with 1 inpatient admission. Once the DBT components of treatment were reintroduced, Andrea’s ER visits again reduced to just one visit. Additional quality of life measures will be presented, along with a discussion of the successes and challenges associated with applying DBT and other evidence-based psychological interventions in this unique context.