title: Successful engagement: a mixed methods study of the approaches of assertive community treatment and community mental health teams in the REACT trial.
abstract: BACKGROUND
  The only randomised trial of assertive community treatment (ACT) carried out in England (the "REACT" study: randomised evaluation of assertive community treatment in North London) found no clinically significant advantage over usual care from community mental health teams (CMHTs). However, ACT clients were more satisfied and better engaged with services. To understand these findings better, we investigated the content of care and interventions offered to study participants.
  
  
  METHODS
  Quantitative data were collected to compare team structures and processes. Qualitative interviews with care co-ordinators of 40 of the 251 REACT study participants (20 ACT, 20 CMHT clients) were carried out and thematic analysis was used to explore differences in the approaches of the two types of team.
  
  
  RESULTS
  CMHTs scored low for ACT model fidelity and ACTTs scored high or ACT-like. All staff cited client engagement as their primary aim, but ACT approaches were less formal, more frequent and more successful than CMHTs'. Two aspects of ACT appeared important for engagement: small case loads and the team approach. Successful client engagement appeared to be associated with greater staff satisfaction.
  
  
  CONCLUSIONS
  The findings from this study assist in understanding why the ACT approach is more acceptable to clients deemed by CMHTs as "hard to engage". The key elements of ACT that facilitate client engagement may not be easily replicated within CMHTs due to their larger, varied caseloads.
authors.affiliation: Dept. of Mental Health Sciences, Royal Free Campus, University College London, Royal Free Hospital, Rowland Hill Street, London, NW3 2PF, UK. h.killaspy@medsch.ucl.ac.uk
authors.forename: Helen
authors.initials: H
authors.lastname: Killaspy
authors.forename: Sonia
authors.initials: S
authors.lastname: Johnson
authors.forename: Barbara
authors.initials: B
authors.lastname: Pierce
authors.forename: Paul
authors.initials: P
authors.lastname: Bebbington
authors.forename: Stephen
authors.initials: S
authors.lastname: Pilling
authors.forename: Fiona
authors.initials: F
authors.lastname: Nolan
authors.forename: Michael
authors.initials: M
authors.lastname: King
mesh_terms: D001242:Assertiveness; D001291:Attitude of Health Personnel; D001521:Behavior Therapy / Q000379:methods*; D003156:Community Mental Health Services / Q000379:methods* / Q000592:standards; D006801:Humans; D008131:London; D001523:Mental Disorders / Q000523:psychology / Q000628:therapy*; D017063:Outcome Assessment, Health Care; D010348:Patient Care Team; D011369:Professional-Patient Relations; D036301:Qualitative Research; D016032:Randomized Controlled Trials as Topic / Q000379:methods* / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires