Therapeutic limit setting in an assertive community treatment program.
OBJECTIVE
The study examined the use of therapeutic limit-setting activities by members of assertive community treatment teams with clients who had serious mental illness.


METHODS
Case managers from 40 Veterans Affairs intensive psychiatric community care teams reported their use of 25 limit-setting activities with 1,564 veterans during the first six months of treatment. The 25-item measurement scale was factor analyzed, and a standard multiple regression procedure was used to regress scale scores on clients' characteristics, the frequency of case managers' contact with service providers and others, and clients' and case managers' perceptions about the therapeutic alliance.


RESULTS
Case managers relied most frequently on informal verbal approaches to limit setting and relied least on formal legal restrictions. Factor analysis of the instrument, the Therapeutic Limit Setting (TLS) scale, reduced the number of items to 20 and resulted in a five-factor solution. The limit-setting factors were verbal guidance, money management, contingent withholding of services or support, enforced hospitalization, and invocation of external authorities. The TLS and its subscales were characterized by high internal consistency, modest intercorrelation, and unique relationships with variables related to clients' characteristics, the treatment process, and the therapeutic alliance. Case managers were more likely to set limits with clients who had more extensive hospitalization histories, a representative payee, recent alcohol or drug use, more arrests, and more severe symptoms.


CONCLUSIONS
Case managers used a range of limit-setting strategies in assertive community treatment. Limit setting is a frequent and potentially important aspect of assertive community treatment that may be useful for comparing levels of assertiveness in assertive community treatment teams and other community-based rehabilitation services.
Neale
M S
MS
Veterans Affairs Northeast Program Evaluation Center, VA Connecticut Healthcare System, Campbell Avenue, West Haven, Connecticut, 06156, USA. michael.neale@med.va.gov
Rosenheck
R A
RA
D001242:Assertiveness; D001521:Behavior Therapy; D019090:Case Management; D003156:Community Mental Health Services; D017831:Diagnosis, Dual (Psychiatry); D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010348:Patient Care Team; D011369:Professional-Patient Relations; D011618:Psychotic Disorders / Q000175:diagnosis / Q000523:psychology / Q000534:rehabilitation*; D012944:Social Support; D019966:Substance-Related Disorders / Q000175:diagnosis / Q000523:psychology / Q000534:rehabilitation*; D016896:Treatment Outcome; D014728:Veterans / Q000523:psychology*