Interviewing and Assertive Community Treatment:
A Case for Training ACT Teams
Trevor J. Manthey,
Office of Mental
Health Research and Training
University of Kansas
School of Social Welfare
Lilac Lane, Lawrence,
Shannon Blajeski, MSW
Maria Monroe-DeVita, Ph.D.
for Mental Health Research and Training
Washington Department of Psychiatry and Behavioral Sciences
Eastlake Avenue East, Suite 200, Seattle,
Manthey TJ, Blajeski S & Monroe-DeVita M. (2012). Motivational Interviewing and Assertive Community
Treatment: A Case for Training ACT Teams. International Journal of
Psychosocial Rehabilitation. Vol 16(1) 5-16
All Correspondence can be sent to Trevor J. Manthey at email@example.com
Interviewing (MI) is an evidence-based clinical intervention that has
shown positive outcomes for individuals with co-occurring serious
mental illness and substance use disorders. Many of these
individuals are similar to those served by Assertive Community
Treatment (ACT) teams, highlighting that MI is an important
intervention and a beneficial modality to be used within ACT
teams. This article examines areas of treatment (assertive
engagement, Integrated Dual Disorder Treatment and person-centered
planning) which both utilize MI techniques and are considered an
integral part of ACT services. These three areas of treatment are
also assessed within the Tool for Measurement of Assertive Community
Treatment (TMACT), an instrument used to assess fidelity to the ACT
model. Lessons learned from the implementation, training and fidelity
measurement of ACT teams in Washington State and recommendations for
future MI implementation within ACT teams are described.
Assertive Community Treatment, Motivational Interviewing, assertive
engagement, person centered planning, Integrated Dual Disorder
Community Treatment (ACT) is a transdisciplinary team approach to
providing treatment and rehabilitation to adults with severe and
persistent mental illness, major functional impairments, and continuous
high service needs within their community. It is the most widely
studied evidence-based practice for this population and has
consistently shown positive outcomes in the areas of decreased
psychiatric hospitalization, improved housing stability, retention in
treatment, and consumer and family satisfaction with services (Bond,
Drake, Mueser, & Latimer, 2001).
service provision that are not always fully implemented by ACT teams
include assertive engagement, Integrated Dual Disorder Treatment (IDDT)
and person-centered planning. Based on IDDT research (Drake,
Mueser, Burnette, & McHugo, 2004) and promising work in these areas
with similar populations (e.g., Adams & Grieder, 2005; Tondora,
Pocklington, Gorges, Osher, & Davidson, 2005) these three specific
service areas are hypothesized to have additional positive outcomes
within ACT, thereby improving the quality of ACT treatment and
rehabilitation. The authors have utilized the Tool for
Measurement of Assertive Community Treatment (TMACT), an instrument
used to assess fidelity to the ACT model (Monroe-DeVita, Teague, &
Moser, in press) in the implementation and ongoing training and
technical assistance to ACT teams in Washington State. In
addition to measuring other core elements of ACT, the TMACT encourages
the acquisition and application of Motivational Interviewing (MI)
skills, particularly in the areas of assertive engagement, IDDT, and
person-centered planning. This article reviews the evidence base
for utilization of MI within ACT teams across these three treatment
areas and makes recommendations for ongoing training in MI within ACT.
The Evidence Base for MI in ACT
Interviewing, listed on the National Registry of Evidence-based
Programs and Practices as an EBP (2009), has been included in over 200
published outcome studies (Wagner & Conners, 2010). In
addition, many separate meta-analyses have reported an overall
significant effect (Hettema, Steele, & Miller, 2005; Rubak,
Sandboek, Lauritzen, & Christensen, 2005; Burke, Arkowitz, and
Menchola, 2003; Lundahl, Tollefson, Gambles, Brownell & Burke,
2010). Based on these findings it has been suggested that MI
outperforms traditional interventions in the treatment of a variety of
behavior change issues. These behavior change issues are similar
if not identical to those addressed by areas of ACT teams’ service
provision and include treatment of dual disorders (Martino,
Carroll, Kostas, Perkins, & Rounsaville, 2002), mental health
(Arkowitz, Westra, Miller, & Rollnick, 2007), physical health
(Rollnick, Miller, & Butler, 2008), medication adherence (McCracken
& Corrigan, 2008), prevention programming (Bennett, Stoops, Call,
& Flett, 2007), homelessness (Fisk, Sells, & Rowe, 2007), HIV
risk reduction (Koblin, Chesney, Coates, et al., 2004), probation
(Harper & Hardy, 2002) criminal justice (McMurran, 2009), supported
employment (Larson, 2008), and vocational rehabilitation (Lloyd, 2008;
Findings further support using
MI to decrease substance use with individuals who experience
co-occurring schizophrenia or schizoaffective disorders and most
substance abuse disorders (e.g. Barrowclough, Haddock, Tarrier, Lewis
et al., 2001; Bellack & DiClemente, 1999; Graeber, Moyers,
Griffith, Guajardo, & Tonnigan, 2003; Ziedonis & Trudeau, 1997;
Martino et al., 2002; Handmaker, Packard, & Conforti, 2002,
Steinberg, Ziedonis, Krejci, & Brandon, 2004; Carey, Purnine,
Maisto, & Carey, 2001). Motivational Interviewing has also
been found to help individuals with a psychiatric disability transition
from inpatient to outpatient settings (Swanson, Pantalon, & Cohen,
1999), and to improve attendance and involvement in dual diagnosis
treatment (Martino, Carroll, O’Malley, & Rounsaville, 2000). In
addition, most consumers with a psychiatric disability who receive MI
respond positively regarding its value and helpfulness (e.g. Franklin,
Murphy, Cameron, Ramirez, et al., 1999).
meta-analysis conducted by Hettema (2005) found that the effects of MI
appear to persist or increase over time when added to an active
treatment. This was termed the additive effect. The additive effect
appeared to have more potency and effectiveness over time than either
MI or the active treatment when delivered alone. This finding
lends further credibility to the idea that adding MI to ACT teams (an
active treatment model) could increase the effectiveness of ACT team
ACT Treatment Areas Utilizing MI
Mulder, Roosenschoon, and Wiersma (2009) recommend utilizing MI for
addressing problems of motivation for individuals within ACT. The
following section expands on this recommendation by outlining three
distinct areas of ACT treatment outlined within the TMACT where MI is
recommended as a beneficial modality: assertive engagement, Integrated
Dual Disorder Treatment, and person-centered planning.
with a dual diagnosis (severe mental illness and co-occurring substance
use disorders) often lack motivation to manage psychiatric symptoms and
pursue employment or other functional goals (Drake, Essock, Shaner,
Carey, Minkoff, et al., 2001). Therefore, ACT teams sometimes
need to do some additional work to engage consumers to be an active
participant in services. Further, to meet fidelity to the ACT
model, teams are required to utilize assertive engagement techniques
for the purpose of retaining consumers, engaging them in treatment and
fostering therapeutic relationships (Monroe-DeVita, Teague, &
Moser, in press). According to the TMACT fidelity protocol, the team
should use an array of techniques including (a) collaborative,
motivational interventions to engage consumers and build intrinsic
motivation for receiving services from the team (b) when necessary,
therapeutic limit-setting interventions to create extrinsic motivation
for receiving services deemed necessary to prevent harm to the consumer
or to others (when therapeutic limit-setting interventions are used,
there is a focus on instilling autonomy as quickly as possible) and (c)
thoughtful processes for measuring effectiveness of engagement
techniques and adjusting them appropriately.
individuals tap into intrinsic motivation can create long-term behavior
change, while using external or compliance-based motivation often
creates only short-term behavior change (Miller & Rollnick,
2002). Unfortunately, sometimes practitioners on ACT teams may
sacrifice long term behavior change for short term compliance.
Therefore, it is important for ACT teams to utilize MI to gain
understanding of individuals’ goals, wishes and values in order to
facilitate engagement; rather than immediately jumping to
therapeutic-limit setting techniques (such as outpatient involuntary
commitment, payeeship, etc). Using MI allows the practitioner to
both directly involve the individual in their treatment and retain them
in the program.
Integrated Dual Disorder Treatment
50 % of individuals with a psychiatric disability are affected by
substance use disorders (Essock, Mueser, Drake, Covell, McHugo, et al.,
2006). Further, Morrissey, Meyer, & Cuddeback (2007) found no
significant reduction in substance abuse or jail days for individuals
with co-occurring disorders when using the ACT model as a sole
intervention. Implementing Integrated Dual Disorder Treatment
(IDDT) within the structure of ACT teams has been necessary to meet the
needs of individuals who experience co-occurring substance use
disorders and severe mental illness.
model (Mueser, Noordsy, Drake & Fox, 2003) suggests that consumers
with co-occurring disorders be treated from a stage-wise treatment
approach integrating the Transtheoretical stages-of-change model
(Prochaska & Diclemente, 1992) with stages of treatment (see Table
1 for a description of how consumers in different stages can receive
different treatment approaches). Specifically, the IDDT model proposes
that consumers who are assessed to be in early stages of treatment,
based on their early stages of change, be engaged utilizing MI to help
them resolve their ambivalence and discover their own motivations for
decreasing and/or abstaining from substances. This differs from a
traditional chemical dependency treatment approach in that
confrontation is not used when an individual is perceived as resistant.
Examples of Stage-Wise
Substance Abuse Treatment Interventions*
Early Stages of Change
Later Stages of Change
Contemplation and Preparation
The consumer does not recognize that s/he has a problem
with substance use or has no interest in modifying use at this time.
Focus of treatment is outreach, assessment, and building a
working alliance. Services are
provided regardless of ongoing use.
The consumer recognizes that substance use is causing some
problems and is considering a change. In the contemplation stage, the
consumer is more aware about the pros & cons, but ambivalent about change;
whereas in the preparation stage, the consumer is planning for change.
Focus of treatment is education about substances, mental
illness, and their interactions, and identifying pros & cons of use.
Motivational interviewing techniques are essential:
offer reflective listening
assist with goal-setting
develop discrepancy between goals and substance use
conduct decision balance (pros & cons)
roll with resistance to
emphasize personal choice
The consumer is committed to reducing or discontinuing
Focus of treatment is helping her/him make change &
identifying & managing triggers and
money management to avoid using
problem solving to
The consumer has abstained from substance use for at
least 6 months.
Focus of treatment is maintaining abstinence:
develop a relapse
help consumer attend
help build and maintain social supports for
maintain awareness of
vulnerability to relapse
help expand recovery to other areas of life
(parent group, vocational supports)
*Adapted from the TMACT Protocol (Monroe-DeVita, Teague, & Moser, in press)
that research on consumer populations with co-occurring schizophrenia
and substance use disorders cite that low motivation is often an
explanation for poor outcomes in treatment (Drake et al., 2001) and
that ACT teams are developing capacity to provide IDDT, it is
beneficial that ACT clinicians become skilled in MI techniques.
addition to utilizing motivational interventions to engage consumers in
their treatment, it is necessary that ACT teams have a person-centered
perspective (e.g., able to see a participant as a person with normative
needs and desires, rather than a ‘mentally ill person.’).
Outcomes associated with a shift from traditional mental health
treatment planning to person-centered planning include improved access
to treatment, better retention in treatment and improved personal
outcomes that are important to the client (Adams & Grieder, 2005).
Motivational interviewing has been suggested as a means to help
individuals with a psychiatric disability explore and develop
individualized goals and attempt to achieve them (Corrigan, McCracken,
& Holmes, 2001).
Inherent to the MI skill
set is attending to an individual’s goals and values. The MI
practitioner attempts to evoke from within the individual how they
envision themselves reaching their goals and determining how their
current behavior fits or conflicts with what has been identified
(Miller & Rollnick, 2002). Therefore, the process of training
an ACT team in MI may assist clinicians in becoming more
person-centered or more recovery-oriented in their framework. In
this way, MI can add to or enhance a team’s recovery orientation and
their person-centered planning ability, helping them to better engage
consumers in the treatment and rehabilitation process.
Measuring Fidelity for Performance Improvement
assess program fidelity is to evaluate the extent to which a program
adheres to the intended implementation model. Fidelity measures
may assess program elements such as the population to be served,
staffing and staff roles, and specific program processes and
interventions. This is important because high fidelity is tied to
better outcomes across many evidence-based practices, including ACT
(McHugo et al., 1999; Becker et al., 2001).
Tool for Measurement of Assertive Community Treatment (TMACT)
(Monroe-DeVita, Teague, & Moser, in press) is an enhanced version
of the original ACT fidelity scale, the Dartmouth Assertive Community
Treatment Scale (DACTS) (Teague, Bond, Drake, 1998). The TMACT contains
47 items, grouped into six subscales, including: (1) Operations
& Structure, (2) Core Team, (3) Specialist Team, (4) Core
Practices, (5) Evidence-Based Practices, and (6) Person-Centered
Planning and Practices. It was designed, in part, to capture not
only the structural components of an ACT team, but how core services
such as assertive engagement, IDDT and/or person-centered planning are
carried out by a team.
The organization of the
TMACT and the DACTS is very similar; each item is rated on a five-point
behaviorally-anchored scale, ranging from one (not implemented) to five
(fully implemented) and ratings are based on the current structure and
activities of the team (i.e., not future plans). Among the many changes
from the DACTS, the TMACT expands the DACTS fidelity measurement by
rating ACT teams’ use of other evidenced-based clinical modalities
including MI and IDDT. To date, the TMACT has been adopted and
piloted in five states as well as in Japan and Norway, and is being
used by several teams in other states. A recent study using the
TMACT to evaluate ten Washington State ACT teams found that teams
scored significantly lower on the TMACT than on the DACTS at baseline,
six, and 12 months, while also demonstrating greater improvement over
time in comparison, suggesting that the TMACT is a more sensitive
measure of ACT (Monroe-DeVita, Teague, & Moser, in press).
Teams also consistently scored lower in the areas of specialist roles,
integration of other EBPs, and person-centered practices--areas not
assessed by the DACTS--suggesting the need for ACT teams to better
implement specialist roles and apply specific strategies to improve
clinical, functional, and recovery outcomes.
10 ACT teams were concurrently implemented in Washington State
(Bjorklund, Monroe-DeVita, Reed, Toulon, & Morse, 2009). All
10 teams received a TMACT fidelity review at six month intervals for a
total of four reviews per team over a two-year period.
Thereafter, TMACT fidelity reviews continued on a yearly basis.
start-up, all 10 newly-implemented ACT teams were provided a one-day
ACT overview followed by a variety of core skills trainings including
an MI training meant as an exposure to basic skills. In fall 2008
and spring 2009, a Motivational Interviewing Network of Trainers (MINT)
trainer also skilled in the TMACT fidelity scale provided two MI
training sessions scheduled one month apart on-site to each of the 10
teams. The month lag time in between the MI training was purposefully
scheduled in order to allow trainees the opportunity to practice their
MI skills. The practitioners were then able to report to the
trainers where they felt they needed added skill development and
support. The follow-up training and consultations were then
focused on these individualized areas.
summary of TMACT items assessing for the use of MI and a Stage-wise
Treatment approach is noted in Table 2. Performance improvement
is one of the primary foci of a fidelity scale. The TMACT showed
sensitivity to the needs of teams when their scores dropped on the
items illustrated in Table 2. The need for continued MI training
and consultation was noted and generally TMACT fidelity review feedback
sessions often included recommendations for continued MI training.
Scale Items Assessing either Motivational Interviewing or Stage-Wise Treatment
Integrated Dual Disorder Treatment
(Evidenced-Based Practices) (EP7)
Team uses an array
of techniques to engage consumers, including (1) collaborative, motivational
interventions to engage consumers and build intrinsic motivation for
receiving services from team and where necessary, (2) therapeutic
limit-setting interventions to create extrinsic motivation for receiving
services deemed necessary to prevent harm to consumer or others. (3) the team
has a thoughtful process for identifying the need for assertive engagement,
measuring the effectiveness of these techniques, and modifying approach where
Program uses a stage-wise treatment model that is
non-confrontational and the FULL TEAM (1) considers interactions between
mental illness and substance abuse; (2) follows cognitive-behavioral
principles; (3) does not have absolute expectations of abstinence and
supports harm reduction; (4) understands and applies stages of change
readiness in treatment; and (5) is skilled in motivational interviewing.
The team conducts person-centered planning:
(1) development of formative treatment plan ideas based on discussion with
the consumer; (2) conducting regularly scheduled treatment planning meetings;
(3) attendance by key staff, the consumer, and anyone else she/he prefers
(e.g. family), (4) meeting driven by the consumer’s goals and preferences;
and (5) provision of coaching and support to promote self-direction and
leadership within the meeting, as needed.
The substance abuse specialist provides integrated dual disorder
treatment to PACT consumers who have a substance use problem. Core services include: (1) systematic and integrated screening and
assessment; interventions tailored to those in (2) early stages of change
readiness (e.g., outreach, motivational interviewing) and (3) later stages of
change readiness (e.g., CBT, relapse-prevention).
for Dual Disorders Treatment: These include services provided by the
substance abuse specialist as well as other team members well-versed in
integrated, stage-wise treatment for co-occurring disorders. Core services include: (1) systematic and integrated screening and
assessment and interventions tailored to those in (2) early stages of change
readiness (e.g., outreach, motivational interviewing) and (3) later stages of
change readiness (e.g., CBT, relapse-prevention).
Specialist on Team: The team has at least 1.0 FTE staff member designated as
a substance abuse specialist. Preferably this specialist has training or
experience in integrated dual disorder treatment.
from TMACT fidelity instrument (Monroe-DeVita, Teague, & Moser, in press)
Training Motivational Interviewing
improvement on ACT teams cannot be obtained without adequate training
and some agencies have not fully appreciated the intricacy involved in
learning MI (Cahill, 2008). Many agencies have begun training
practitioners in MI through one day single shot workshops, the results
of which have been mixed (Baer, Rosengren, Dunn, Wells, Ogle, &
Hartzler, 2004). In addition, some agencies have tried to have
their staff build MI skills through self directed learning, which is
ineffective (Miller, Yahne, Moyers, Martinez, & Purritano,
2004). Recent training research has shown evidence that the
typical one or two day workshop may not be the best way to learn MI
(Miller & Mount, 2001; Walters, Matson, Baer, & Ziedonis,
2005), and that MI skills are not retained without added supervision
(Heaven, Clegg, & Maguire, 2006). A more effective form of
learning MI after initial training has been shown to be continued
supervision in the form of feedback and coaching (Bennett, Moore,
Vaughan, Rouse, et al., 2007; Miller et al., 2004). One of the
benefits of using the TMACT fidelity scale is that it assesses for
indicators to determine when continued supervision and coaching in MI
In the spirit of
helping to facilitate effective trainings for performance improvement,
suggestions are provided based on concerns verbalized during the
training of MI in Washington State. These suggestions are
depicted in Table 3. Some of the concerns described were
originally detailed in a newsletter for an organization of motivational
interviewing trainers in the context of vocational rehabilitation
(Manthey, 2009) and are repeated here with some adaptations and
additions for the ACT context.
responding to selected concerns expressed by individuals learning MI.
“What if they’re symptomatic?”
It can sometimes be difficult to
use MI with individuals with a psychiatric disorder who are experiencing
Emphasize that one can still function within
the spirit of MI even if circumstances don’t always permit using MI in its
pure intervention form.
Emphasize that there are adaptations of MI
made specifically for individuals with psychiatric disabilities. (See the
following for further information on this topic, Carey, Leontieva, Dimmock,
Maisto, & Batki, 2007; Corrigan, McCracken, & Holmes, 2001; Martino,
Carroll, Kostas, Perkins, & Rounsaville, 2002; and, Rusch & Corrigan,
“Not all of us are therapists!”
Not all ACT team practitioners
are mental health clinicians (e.g. nurses, housing specialists, supported
employment specialists, peer counselors etc) and for some there may be a
desire to avoid interactions that could be construed as therapy.
Emphasize that MI is a way of being with
Emphasize that MI has helped people make
diverse behavior changes in a wide variety of settings, not just therapy.
Spend more time helping people grasp the
spirit of MI.
“What if they don’t change?”
If an individual decides not to
change or fails at their attempt to change than the practitioner may feel as
if they have failed or done a poor job.
Emphasize that within MI choosing not to
change is a legitimate option (even though the likelihood that someone will change
Discuss the importance of not getting attached
to an individual outcome. It is more helpful to improve/develop one’s own
skill set than to try to control the result for each participant.
“I already do this stuff.”
Some trainees report that they
already posses the skills described in the MI training.
Try to avoid confronting these statements,
rather utilize analogies or conduct activities which develop discrepancy
between what participants state they do and what they are actually doing.
“I need lots more practice.”
Some ACT team practitioners
report a lack of confidence in their ability to do MI, even if they
understand MI concepts.
Adding monthly feedback and supervision
portions to the training workshop series increases confidence and skill
development (See Heaven et al., 2006; Miller & Mount, 2001; Miller et
“If they would just listen.”
Assuming the expert role is a
common issue faced by practitioners when learning MI. Once in this role
practitioners will offer unsolicited solutions or advice about how to fix an
There are several behaviors that can help with
this issue discussed by Rollnick et al. (2008): Avoid arguing for change when
the service user is not ready, do not assume practitioners have to offer all
the solutions for change, do not assume the consumer ought to change, wants
to change or that recovery is the prime motivator for them to change.
Emphasize that giving information to consumers
can be beneficial and can occur in MI consistent ways: such as asking
permission before giving advice and providing a menu of opjtions (See Miller
& Rollnick, 2002).
“There isn’t enough time!”
Some ACT teams consistently
function in a state of crisis. Meaning the team is reactive, moving from crisis
to crisis without believing they are able to slow down and conduct proactive
or preventative interventions. When this occurs teams often spend a lot of
time trying to push people into behavior changes rather than drawing out
behavior change from within the person.
Discuss avoiding the premature focus trap (See
Miller & Rollnick, 2002).
Emphasize that MI has been used successfully
in very brief settings such as healthcare and therefore can be a very short
intervention if needed.
further research needs to be conducted to more fully assess the
effectiveness and implementation of MI within an ACT model; this
article clearly lays out the treatment areas where MI skills are
necessary to meet fidelity to the ACT model. Utilization of fidelity
scales are meant to be a continual process and not a one-time
assessment. Therefore, utilizing the TMACT fidelity scale not only
allows assessment of a team’s adherence to the ACT model but also can
provide information such as whether to implement further technical
assistance in other evidence-based practices. Based on the
information described here, recommendations for future implementation
of MI into ACT teams include utilization of the TMACT fidelity protocol
because of its ability to track the use of MI. It is also
recommended that future efforts to implement MI within ACT teams
include additional follow along supports such as supervision and
coaching. This would provide practitioners continued support in
implementing the practice as well as increasing their confidence and
skills. Supervision and coaching would also allow for
consultation with team leaders and staff around using MI to build
relationships with difficult-to-engage participants. Most
importantly, implementing MI provides practitioners on ACT teams with
practical skills that increase their ability to engage consumers into
services, provide Integrated Dual Disorder Treatment, conduct
person-centered planning, and generally increase consumer motivation
for behavior change and recovery.
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