Exploring Needs and Experiences of ACT Providers: A Photovoice Project

Background and Purpose: Assertive Community Treatment (ACT) is an evidence based interdisciplinary service delivery model that provides comprehensive service to individuals with severe and persistent mental illness in their living environments. Despite its documented success in increasing treatment adherence and reducing hospitalizations, little is known about facilitators and barriers to service provision. Understanding provider experiences is critical to decrease ‘burn out’ among ACT providers and enhance the quality of service provision. Thus, the purpose of this study was to document ACT providers’ experiences using photovoice method grounded in the principles of Community Based Participatory Research(CBPR).

Methods: Following CBPR principles which equitably involve and recognize the contributions of Community and Academic partners, two social work doctoral students partnered with two New York ACT teams (Bronx, Manhattan).  Using Photovoice and guided by the SHOWeD method of critical reflection (Dakin et al. 2014), academic partners (AB & DC) facilitated three 1-2-hour long focus group discussions with five ACT team providers. During sessions:  1) the partnership collaboratively identified a community relevant research question; 2) ACT providers took multiple pictures that represented their experiences; 3) the partnership engaged in critical in-depth reflections regarding ACT providers’ photographic representations of their experiences. Sessions were audio recorded, subsequently transcribed (by AB & DC) and collaboratively analyzed using Thematic Analysis (Braun & Clark, 2006) to develop themes and make recommendations for research, practice and policy. 

Findings: ACT providers held multiple roles (social workers, team leaders, vocational specialist) with four participants reporting more than five years of ACT experience.  Participants described positive and challenging experiences in delivering field based direct care to individuals whose SMI is compounded by homelessness and histories of substance abuse. These included: 1) overwhelming and inefficient documentation protocols which reduce face-to-face contact with clients, 2) Interagency conflict, 3) perceived physical and emotional vulnerabilities resulting from their role as ‘first responders’, working in unsafe environments and making critical decisions for clients; and 4) individual (e.g. self-determination, empathy, compassion) and collective strengths (i.e., “team chemistry”) that contribute to the effectiveness of ACT as a model of care, despite the several challenges. 

Conclusion and Implications:  This study demonstrates the value of photovoice as a tool to enable “communities” to reflect on their individual and collective experiences. For ACT providers, the project was ‘therapeutic’ as they could ‘think more deeply about the work that they do’- a rare opportunity due to their intense work schedules. ACT providers made several recommendations to improve the effectiveness of service provision, e.g. ‘finding threads of a unified goal’ to enhance interagency collaboration, demystifying mental illness and ‘humanizing care’. As importantly, ACT providers felt that their work is ‘physically and emotionally taxing’ and shared the multifaceted vulnerabilities they experience while delivering care. Training curriculum for ACT providers should therefore be supportive and sensitive to their needs and experiences. Attending to both the professional and personal realm of being an ACT provider will strengthen their capacities as mental health professionals and in turn positively impact outcomes for ACT service recipients.