Abstract
AN INNOVATIVE USE OF THE ASSERTIVE COMMUNITY-BASED TREATMENT MODEL
Located in Kwinana, 30 km south of Perth, the South Metro Men's Respite (SMMR) uses an innovative Assertive Community-based Treatment (ACT) model to meet gaps in mental health service provision in this geographic area. Three modes of service delivery are employed at the SMMR, including personal crisis counselling, respite accommodation, and issues groups dealing with major areas such as domestic violence (as perpetrator and as victim), suicidal ideations, child access and court support, prison release, homelessness, and substance abuse.
The SMMR operates on the staff philosophy for an ACT model for public and mental health intervention. As one component of this, the staff aim to positively and assertively respond to a walk-in or crisis caller 24 hours a day. This process involves proactively seeking out and gaining personal contact with clients, including visiting off-site distressed clients, no matter the inconvenience or time of day. The SMMR's structure and operation is based on a psycho-educational model where selfawareness, personal responsibility, anger management, rights of others, and problem solving are emphasised using cognitive-behavioural therapy (CBT) and group support strategies.
The ACT model for public and mental health intervention was developed at Mendola Mental Health Institute in Madison, Wisconsin, to address the “revolving-door” hospitalisation experience of individuals with a mental illness. Dixon identifies that it was anticipated that the community would serve as a better venue for treatment than the hospital setting, as the individual could develop skills for coping with problems of living in the community, without shifting the burden of care to the family. 1 The ACT model’ desired outcomes were increased quality and stability of community living, and reduced repeated hospitalisations via community based, non-time limited and nonsequenced service provision. While this model has changed systems of care for individuals with a mental illness, its use has no previous documentation in the outreach and treatment of individuals with a domestic violence problem.
CLIENT PROFILING
Setting and sample
The SMMR has been in operation for just over two years in a semi industrial area known for high unemployment and low SES. The region once served as an industry hub for industrial manufacture, transport and shipping but had declined economically since the early 1980's. Two local area police agencies reported that SMMR's catchment area had “a much higher” rate of domestic violence than other comparable locales. Police, mental health, general practitioner, and drug rehabilitation make up 28%, 14%, 8%, and 8% of SMMR referrals, respectively. At the time of the study, a managing coordinator, six minimally trained counsellors, two administrative assistants, two night attendants, and six volunteers staffed the SMMR.
The current evaluation assessed 45 clients presenting for counselling or respite services at the SMMR over a six week period. Each male completed a Brief Symptom Inventory for the purpose of identifying mental illness.
Measure
The Brief Symptom Inventory (BSI) provides a measure of psychological distress as expressed through symptoms of mental functioning. 2 The BSI is a self-report instrument that has been used in over 250 studies. It has an inter-item reliability ranging from 0.71 to 0.85, and test-retest reliability from 0.70 to 0.91.
The BSI's 54 items indicate symptom sub-patterns of somatisation, obsessive-compulsiveness, inter-personal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. Each item is rated on a five-point scale of distress, ranging from “not at all” (0) to “extremely” (4). A Global Symptom Severity Index (GSI) may be calculated by summing the subscale scores and then dividing by the number of responses. This indicates an overall measure of signs of mental illness. Furthermore, the BSI provides normative data on relevant populations such as psychiatric patients and adult male non-patients.
RESULTS
The demographic characteristics of the men presenting to the SMMR during the data collection period are displayed in terms of age and ethnic background in Tables 1 and 2 respectively.
The BSI mean scores for the nine subscales and the GSI for the 45 men who accessed SMMR services during the six week period are presented in Table 3. The means from three male norm groups are also provided for comparison (Psychiatric Outpatient, Psychiatric Inpatient, and Adult Non-psychiatric). The SMMR sample had higher mean scores on all subscales for all referenced groups. Further, the SMMR sample had a substantially higher score on the overall indicator of symptoms/distress, the Global Severity Index.
The highest subscale scores were on Depression, Obsession and Paranoid Ideation. The next highest scores were on Anxiety, Interpersonal Sensitivity and Psychoticism. Lowest scores were on Hostility, Somatisation and Phobia. All scores were elevated in comparison to the three normative groups (six to nine times elevated over the Adult Non-psychiatric men). An analysis of variance and resulting F-test indicated an overall significant difference among groups, F(3,985)= 197.01, P < 0.0001, and a subsequent Student-Neuman-Keuls' test indicated significant differences between all groups in six comparisons, all significant at α= 0.05.
Age distribution of clients at the South Metro Men's Respite (SMMR)
Ethnic background of clients
BSI subscales: measures of dispersion in comparing four groups
To identify cases symptomatic of mental illness, the BSI attempts to detect “caseness” (i.e. existence of a clinical problem) operationally by the use of selection criteria. In the present study, the researchers selected the first criteria, that is, a T score for any two subscales equalling or exceeding 63 is considered symptomatic of mental illness in the adult non-patient population. This resulted in 63% of the men deemed symptomatic of mental illness.
In addition to the first mental illness screening rule, two screenings using more conservative rules were employed to gauge the state of severe mental illness in the sample. The first was to count, as cases, those men who had at least eight of the subscale scores equal or exceeding the T score cutoff value of 63, using the original Derogatis norms for male non-patients. The second was to use these same T score cut-offs but this time for male psychiatric outpatient norms. Thus, increasingly narrower parameters were employed for identifying those with mental illness symptoms.
As presented in Table 4, the use of the more restrictive eight-scale criterion for severe mental illness identified 49% of the SMMR sample having severe mental illness symptoms (caseness). Using the same eight
Identification of cases using increasingly
scale criterion, but with T scores for the psychiatric outpatient norms, resulted in 35% of the SMMR sample being identified as having severe mental illness. Thus, while the overall percentage of mental illness decreased by tightening the mental illness/severe mental illness criteria, there was still a substantial percentage (35%) of clients in the sample who presented with symptoms of severe mental illness.
Comparison with other programs
Seven programs for male perpetrators that appeared prima facie to match SMMR were identified via Internet searches, a literature review and key informants for the purpose of comparing service structure. Of these, only three provided statistics, brochures and annual reports/descriptions that enabled the conclusion that they were similar in structure, mission and components to SMMR. Of the three, only two seemed to be “integrated” (comprehensive, multi-
service, and assertive) and thus near matches to SMMR. These two programs, Ozanam House (Melbourne, Victoria) and Leeside (Doveton, Victoria) used similar residential, multi-service, case integrated case management systems (program logics). They also employed interventions using an “Edward Gondolf” 3 model of taking personal responsibility, cognitive-behavioural retraining, residential support and anger management. All seven programs dealt with content in child custody/parenting, spousal independence, addiction, personal responsibility, alternatives to violence, gender roles, and communication.
DISCUSSION
The evaluation results suggest that even with an increasingly stringent BSI assessment criterion, a large number of the SMMR's presenting clients displayed symptoms of mental illness/severe mental illness. These results can be compared to the profiling of Gondolf. 4 In his study of 840 perpetrators of domestic violence, the Millon Clinical Multiaxial Inventory III (MCMI-III) 5 revealed 48% of his sample as mental illness and 25% as severe mental illness. The BSI is a state dependent measure of mental disorder or distress. As such, it is not considered conceptually or methodologically based around the Diagnostic and Statistical Manual of Mental Disorders 6 or other personality theory, as is the MCMI-III. Even so, the percentages of mental illness/severe mental illness were similar between these two studies, suggesting that a proportion of clients presenting to services such as the SMMR display such symptoms.
Of the BSI subscales, depression, anxiety, paranoia, and psychoticism are representative of areas associated with severe mental illness, and would thus indicate domains for treatment concern. The highest subscale score for the SMMR client group was on the depressive distress symptomology. Essock and Kontos recognise that for individuals with a severe mental illness such as major depression, ACT programs lead to more favourable outcomes for the individual than that of generalist case management. 7 Rosie et al. further recognise the value of ACT in the treatment of patients with excessive anxiety. 8 The SMMR sample indicated levels of anxiety higher than that of the adult male psychiatric inpatients and outpatients, which would imply the suitability of the ACT program at the service.
Although the ACT model appears, at face value, to match the needs of some SMMR clients, one must consider that ACT programs were primarily designed for low-functioning mentally ill individuals without the resources to develop skills for coping with problems of living in the community. In the case of the SMMR, clients are already living in the community, but have specific problems related to violence, with some evidence of concurring mental illness. The use of the aggressive outreach component of ACT has not been previously assessed in such a population. Thus, one cannot conclude its appropriateness without firstly establishing the level of reluctance for perpetrators of domestic violence to proactively seek help for their problems, and secondly conducting an outcomes assessment to examine the success of the ACT philosophy in the mens' domestic violence service setting.
In light of these suggestions, the SMMR's innovative approach aims to meet service gaps in providing for men who are perpetrators of domestic violence. The service comparison review established that while seven other programs within Australia had provisions for child custody/parenting, spousal independence, addiction, personal responsibility, alternatives to violence, gender roles, and communication content, the ability to provide assertive outreach to the men was shared by only two other programs in Australia. It is this unique concept that is hoped to reduce domestic violence incidence by providing the men with an ongoing support strategy. The incidence of previously undiagnosed mental illness recognised within the client base in this study suggests directions for future program development in terms of diagnostic and treatment needs.
ACKNOWLEDGEMENTS
The Centre for Mental Health Services Research acknowledges the financial support of the Health Department of WA. However, the Health Department of WA is not responsible for the contents of this publication and any views or opinions expressed herein do not necessarily represent those of the Department.