Clinicians' and Clients' Perspectives on the Impact of Assertive Community Treatment

OBJECTIVE: Clients in an assertive community treatment program and their clinicians were asked to rate clients' current difficulties in 13 quality-of-life areas to determine whether improvement in any area predicted reductions in hospitalization and incarceration. METHODS: A peer counselor interviewed 45 clients about psychiatric symptoms, substance use and abuse, medical issues, medication compliance, primary supports, social supports, vocational and occupational issues, housing, daily living skills, economic issues and entitlements, legal involvement, behavioral issues, and treatment involvement. The clients' clinicians rated the clients in these same areas. Ratings of clients' difficulties in these areas at program entry were based on combined ratings made at intake and after a review of clients' charts. Data on hospitalization and incarceration were obtained from medical and police records. Logistic regression analyses were used to seek predictors of declines in admissions to hospitals and jails (referred to as institutional admissions). RESULTS: Institutional admissions decreased after program entry; decreases were larger among clients admitted in recent years. Clients improved significantly in all 13 quality-of-life areas based on comparisons of both clinicians' and clients' ratings and baseline ratings; however, clients rated themselves as having less difficulty than their clinicians thought they had in the areas of substance abuse, medication compliance, primary supports, social supports, daily living skills, and treatment involvement. Based on clinicians' ratings, improvement in substance abuse issues predicted declines in institutionalized admissions. Based on clients' ratings, improvement in social support and economic issues predicted declines. CONCLUSIONS: These findings emphasize the importance of clients' perspectives in treatment planning and suggest that clinicians may overlook the smaller incremental steps toward improvement that are valued by clients.