ASSERTIVE COMMUNITY TREATMENT (ACT) SERVICES:
CULTURAL COMPETENCE, CLIENT-CENTRICITY, AND THE ROLE OF
THE SOCIAL WORKER
by
Rahul Jain
Ph.D., University ofRajasthan, 2009

PRACTICUM SUBMITTED IN PARTIAL FULFILLMENT OF
THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SOCIAL WORK

UNIVERSITY OF NORTHERN BRITISH COLUMBIA
October 2013

© Rahul Jain, 2013
UNIVERSilY of NORT>-!ERN
BRITISH COLUMBIA
LIBRARY

Prince George, B.C.

11

Abstract

This practicum report details my experiences in respect of the Assertive Community
Treatment (ACT) program under Mental Health and Addictions Services, Northern Health
Authority, Prince George, British Columbia, supplemented by a description of the outcome of
my visit to the ACT program of the Community Support Network at Northcoast Behavioral
Healthcare System, Ohio, USA.
My practicum learning goals pertained to the following aspects of ACT, especially in the
context ofNorthem Aboriginal communities: procedures, services and clinical social work skills;
client-centric and culturally competent treatment/services/support; and community settings. The
report, therefore, gives an account of my activities and tasks, and details the outcomes. It
includes statements of ACT team members as well as their experiences that contributed to my
understanding of ACT application in the real world scenario. Anti-oppressive Social Work
Practice and Aboriginal Healing Models form the theoretical frameworks of my practicum. The
report also discusses the issues and challenges associated with ACT, apart from carrying my
personal reflections.

111

TABLE OF CONTENTS
Abstract

11

Table of Contents

111

Glossary

v

Acknowledgements

Vll

1

Introduction
Chapter One

Northern Health ACT Office and Practicum Learning Goals
Assertive Community Treatment
Cultural Competence and Aboriginal Healing
Practicum Site: Organizational Information
Practicum Leaning Goals
Significance of the Practicum
Alignment with BC Program Standards
Theoretical Framework
Aboriginal Clients and Limitations of Mainstream Treatment

3
3
6
9
12
13
13
14
16

Chapter Two

Literature Review
Cultural Competence and Healthcare for Ethnic Minorities
Barriers Faced by Service Users and their Perceptions and Experiences
Examination of Effectiveness of Cultural Competence of Healthcare
System and Integration ofTraditional Healing and Mainstream Treatment
ACT and Cultural Factor
ACT and Related Issues

18
18
20

Chapter Three Activities, Tasks, Learning
Activities
Assessments and Charting
Reaching out to Clients
Active Participation in Interdisciplinary Team Meetings
Gaining Knowledge about Most Common Clinical Syndromes
and Most Common Psychotropic Medicines
Critical Incident Stress Debriefing
Visits
Specific Tasks
Practical Learning
I. ACT Procedures, Client-Centric Services, and Social Worker Role
Social Worker on ACT Team
Values and Skills
Engaging Families
Working with Other ACT Members

21
25
25
27
27
27
29
30
30
32
33
34
35
35
35
37
38
39

IV

ACT Procedures, and Client-Centric Services
Referral
Camberwell Assessment ofNeed-Clinical version
Recovery Plan
Description of Comprehensive Assessments
Discharge Planning
Team Members' Statement
II. Culturally Competent Services
III. ACT and Community Work
Community Resources
IV. Visit to Northcoast Behavioral Healthcare System, Ohio

39
39

40

41
42

44
45

46
48

49

50
55

Chapter Four

Issues and Challenges
Personal Reflections

58

Chapter Five

Conclusion

62

References

64

Appendix

74

v
Glossary
Aboriginal Healing: The beliefs, values and practices associated with traditional healing
practiced by Aboriginals.
Assertive Community Treatment (ACT): Client-centered, recovery-oriented treatment provided
by a multidisciplinary mental health staff for community reintegration of clients.
Bipolar Disorder: Bipolar disorder, also known as manic-depressive illness, is a brain disorder
that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day
tasks.
CAN-C: A tool for the comprehensive assessment of the needs of the people with severe mental
health problems. Its full form is Camberwell Assessment ofNeed-Clinical Version.
Client Empowerment: The choice of clients in choosing interventions, which involves cultural
needs and preferences.
Community Support Network (CSN): Community mental health services provided by state
mental health workers to people with severe mental health illnesses who are living in the
community.
Critical Incident: Any situation faced by employees that causes them to experience unusually
strong emotional reactions and that has the potential to interfere with their ability to function.
Cultural Competence: The capacity to provide effective healthcare taking into consideration
people's cultural beliefs, behaviours, and needs.
Diagnostic and Statistical Manual of Mental Disorders (DSM): The standard classification of
mental disorders used by mental health professionals in the United States and elsewhere.
Mania: Frenzied, abnormally excited mood.

Vl

PharmaNet: A British Columbia (B.C.)-wide network that links all B.C. pharmacies to a central
set of data systems.
Schizophrenia: A complex biochemical brain disorder that affects a person' s ability to determine
what is reality and what is not, resulting in delusions, hallucinations, social withdrawal, and
disturbed thinking.
SYNAPSE: An electronic database for recording the daily activities and assessment of clients.
Sources: American Psychiatric Association, Canadian Mental Health Association, National
Institute of Mental Health (Maryland, USA), Northcoast Behavioral Healthcare System
documents, Northern Health Authority documents, Papadopoulos (2003).

Vll

ACKNOWLEDGEMENTS
At the outset, I express my deepest gratitude to Prof. Glen Schmidt, my Academic
Supervisor and mentor, for his continued support, encouragement, and inspiration that richly
contributed to the successful completion of my MSW program. This apart, Prof. Schmidt lent a
great support in facilitating my recent visit to Ohio, U.S.A. for the practicum.
I wish to sincerely thank Mr. Glenn Beach, the ACT Team Leader and my Practicum
Supervisor, whose timely assistance and enthusiastic support to my practicum was an enormous
help. He granted me an interview and his enlightening and articulate responses to my questions
proved very useful.
I am extremely thankful to Ms. Suzanne Campbell for her clinical supervision, whose
solid support came to me in numerous ways. I learned a lot from her in terms of skills and
knowledge.
My heartfelt thanks go out to all my instructors of Social Work, especially Dr. Nancy
Jokinen who is also my Practicum Committee Member and has been a source of great strength,
valuable guidance, and inspiration throughout the program.
I wish to thank Ms. Dawn Hemmingway, Head of Department, School of Social Work
for her encouragement.
I also acknowledge my thanks to Ms. Sandra MacDonald, my MSW foundation year
practicum supervisor, for her consistent guidance and support throughout my MSW program.
I will be failing in my duties if I do not acknowledge my deepest thanks to all the ACT
team members who readily agreed to be interviewed and who gave substantive, forthright, and
insightful responses.

Vlll

In the last phase of my practicum, Ms. Sonja Benford, Clinical Supervisor, ACT Team,
Northcoast Behavioral Healthcare System, Ohio was kind and generous in granting me an
interview, sharing her professional experiences, and making available richly relevant literature.
She introduced me to several programs ofNBHS and took me to the Northfield ACT office. For
all this, I express my heartfelt gratitude to Ms. Benford. I am thankful to the NBHS team for a
wonderful interaction.
Further, I wish to thank the clients whom I worked and interacted with. Also, my sincere
thanks go out to all those organizations that I visited during my practicum to achieve my learning
goals.
I must not forget to thank Ms. Heather Lamb who was generous enough to share her
MSW practicum report with me that gave me a fairly good idea about the structure and contents
of the report.
I am greatly thankful to Ms. Ramandeep Kaur for her unstinted encouragement and
support during my MSW program.
I have no adequate words to express my simple thanks to my parents and sister for their
constant moral support, care, and guidance.

1

Introduction

This practicum enriched my professional understanding of ACT, especially in respect of
client-centricity and culturally competent services. These components are integral to ACT,
especially since individualized services are a predominant characteristic of ACT. Interaction with
ACT team members who have hands-on experience in delivering ACT services and who had
been extremely forthcoming in responding to my queries, greatly benefited me in terms of
learning about the challenges and issues involved in providing ACT, for example, ethical
dilemmas and implementation issues. Undoubtedly, professional codes of conduct and
organizational policies can direct and instruct a social worker how to fulfill the professional role,
but learning from experienced and on-field practitioners is a big advantage. In addition, my
MSW courses enabled me to understand the ethical dilemmas in social work practice and the
importance of client empowerment, which in tum helped me in my practicum.
In order to achieve my practicum learning goals, I felt an urge to gain cross-national
insights into client-centric and culturally competent services. As such, I am glad I was able to
visit Northcoast Behavioral Healthcare System (NBHS) in Northfield, Ohio, and interact with its
ACT staff.
I supplemented my practicum tasks through research into ACT, cultural competence, and
the traditional healing method used by Aboriginals. I think this exercise was essential in gaining
a greater understanding of cultural aspects of treatment that takes applied, theoretical, and
conceptual parameters into account. This will be beneficial for me as a practitioner since the
circumstances in which I might find myself might vary regionally. In other words, there are no
ready-made solutions-keeping oneself updated on literature helps. I have incorporated the
research findings in chapter one as well as the literature review section.

2
This report consists of five chapters. Chapter One introduces ACT, Cultural Competence,
and the Aboriginal Healing Method, given the paramount significance of these terms for my
practicum. Subsequently, information about Northern Health, where I did my practicum, has
been provided, followed by my practicum learning goals. The chapter ends with a description of
the significance of my practicum. Chapter Two provides a brief critical review of the relevant
literature. Chapter Three describes the activities and tasks that I undertook to achieve my
learning goals. It then describes my practical gains. Chapter Four spells out the issues and
challenges involved in providing ACT. It also contains my personal reflections and observations.
Chapter Five provides the conclusion.
It may be added that the identity of interviewees (ACT team members) has been kept

anonymous for the sake of confidentiality.

3
Chapter 1
Northern Health ACT Office and Practicum Learning Goals
This chapter introduces the reader to my practicum site as well as my learning goals.
Prior to this, it provides an introduction to Assertive Community Treatment, Cultural
Competence, and Aboriginal Healing Approach, which are associated with the practicum topic.
Assertive Community Treatment
Assertive Community Treatment (ACT) is a client-centred, recovery-oriented service
delivery model for clients with the most serious mental illnesses and substance use disorders. Its
origin is traced to the ' training in community living' programme that was launched during the
1970s at the Mendota Mental Health Institute in Madison, Wisconsin (Marx, Test, & Stein,
1973) by its medical professionals who realized the need for an effective community treatment
programme to prevent clients' rehospitalisation. The ACT model, unlike the traditional system of
care, involves a multidisciplinary staff that works as a team in delivering the majority of
treatment, rehabilitation, and support services required by each client in community locations
(British Columbia Ministry of Health Services, 2008). The team typically comprises: a team
coordinator, a psychiatrist, registered nurses, a social worker, an occupational therapist, a
substance abuse specialist, a life skills worker, a vocational specialist, a peer support specialist,
and a program assistant. Research shows that ACT, evidence-based practice, has yielded positive
outcomes in terms of reducing hospitalization, enhancing housing stability, and bettering the
lives ofthe recipients (Calsyn, 1998; Philips, 2001; Santos, 1993).
ACT, as a recovery-oriented treatment, is based on the Psychosocial Rehabilitation
Model, which:

4

promotes personal recovery, successful community integration, and satisfactory quality
of life for persons who have a mental illness or mental health concern. Psychosocial
rehabilitation (PSR) services and supports are collaborative, person directed, and
individualized, and an essential element of the human services spectrum. (About PSR
Canada, n.d.)
Its main principles are as follows:
1. Psychosocial rehabilitation practitioners believe that all individuals have the capacity for
learning and growth.
2. Psychosocial rehabilitation practitioners recognize that culture and diversity are central to
recovery.
3. Psychosocial rehabilitation practitioners engage in the processes of informed and shared
decision-making.
4. Psychosocial rehabilitation practices build on strengths and capacities of individuals
receiving services and supports.
5. Psychosocial rehabilitation practices are person-centered; they are designed to address the
distinct needs of individuals, consistent with their values, hopes and aspirations.
6. Psychosocial rehabilitation practices support full integration of people in recovery into
their communities.
7. Psychosocial rehabilitation practices promote self-determination and empowerment.
8. Psychosocial rehabilitation practices facilitate the development of personal support
networks by utilizing natural supports within communities or family members.

5

9. Psychosocial rehabilitation practices strive to help individuals improve the quality of all
aspects of their lives, including social, occupational, educational, residential, intellectual,
spiritual and financial.
10. Psychosocial rehabilitation practices promote health and wellness, encouraging
individuals to develop and use individualized wellness plans (About PSR Canada).
Philips et.al (2001) spell out the following major principles of ACT:
•

Specific Target Group-Services are targeted to a specified group of individuals with
severe mental illness.

•

Staff as a Team-Rather than brokering services, treatment, support, and
rehabilitation services are provided directly by the assertive community treatment
team that shares the responsibility.

•

Small Staff-Client Ratio-The staff-to-client ratio is usually 1 to 10.

•

Comprehensive Services-The range of treatment and services is comprehensive and
flexible.

•

Community Locations-Interventions are carried out at the locations where problems
occur and support is needed rather than in hospital or clinic settings.

•

Client-centered- Treatment and support services are individualized.

•

Regular Services-Services are available on a 24-hour basis.

•

Team Assertion-The team is assertive in engaging individuals in treatment and
monitoring their progress (p.773).

It may be mentioned that the first ACT team in Canada was formed at Brockville

Psychiatric Hospital in 1989/90. As far as Standards for ACT programs are concerned, they
originated in the United States. They were improved, refined, and articulated in the form of the

6
British Columbia Program Standards for ACT Teams under the auspices of the British Columbia
Ministry of Health Services (2008), according to which: "Client empowerment, involvement, and
choice are fundamental to individualized, collaborative and effective ACT service delivery"
(p.iii). According to Saleebey (2001), empowerment "indicates the intent to, and the process of,
assisting individuals, groups, families and communities to discover and expend the resources and
tools within and around them" (p.9). This report touches on the empowerment aspect by dealing
with client-centric care.
Cultural Competence and Aboriginal Healing
Culture-based intervention has been considered important in northern social work
practice as part of holistic healing. It involves provision of culturally sensitive treatment, use of
clients' cultural practices, and understanding of their cultural traditions, values and beliefs
concerning health in order to provide quality care and service. In the words of Papadopoulos
(2003), cultural competence is " ... capacity to provide effective healthcare taking into
consideration people's cultural beliefs, behaviours and needs ... cultural competence is synthesis
of a lot of knowledge and skills which we acquire during our personal and professional lives and
to which we are constantly adding .. ." (p.3). The table below is based on Sue's tripartite
framework (Centre for Addiction and Mental Health, 2004).
Table 1
Sue 's tripartite framework
Awareness of Own Cultural Values and Biases
•
•
•
•

Aware of and sensitive to own cultural heritage and self-identity with relation to
ethnic and cultural definitions.
Aware of own background/experiences, values and biases and how they influence
psychological processes and affect clients.
Able to recognize the limits of own multicultural competency and expertise.
Acknowledges and is aware of own racist, sexist, heterosexist, or other
detrimental attitudes, beliefs, and feelings.

7
•
•
•
•
•
•

Aware of differences between self and clients in terms of race, gender, sexual
orientation and other socio-demographic variables.
Aware of cultural transference and counter-transference and defensive reactions.
Engage in critical self-reflection regarding personal identity and attitudes to other
groups, self-monitoring, and self-correction.
Understanding of how oppression and discrimination personally affect oneself
and one ' s work.
Values and respects wellness, self-care and self-awareness.
Valuing and respecting humility and willingness to learn from others; openmindedness.
Awareness of Client's Worldview

•
•
•
•
•

Values/respects differences, diversity among and within a cultural group.
Respects religious and/or spiritual beliefs of others.
Respects indigenous helping practices and community networks.
Values bilingualism.
Can be non-judgemental.
Knowledge

Culture-Specific (Ernie)
•
Possesses specific knowledge of normative values/beliefs about illness,
normality/ abnormality, help-seeking behaviour, culturally unique symptoms
and interventions, interactional styles, and worldview of main cultural groups
with which one is working.
•
Possesses enough knowledge about cultures one serves to avoid breaching
client' s taboos, health care beliefs, or rules of interaction.
•
Knowledge of service resources for culturally-appropriate care.
Culture-Generic (Etic)
•
Aware of institutional barriers that prevent some diverse clients from using
mental health services.
•
Knowledge of history, experience and consequences of oppression, prejudice,
discrimination, racism, and structural inequalities
•
Understands culture-bound, class-bound, and linguistic features of
psychological help/interventions.
Skills
Engagement
• Establishing rapport and therapeutic alliance in culturally congruent way
considering culture-bound interpretations of verbal and nonverbal cues, personal
space, and eye contact.
• Cultural empathy.
Assessment/Feedback
• Ability to assess issues as client's level of acculturation, acculturative stress, and
stage of gay or lesbian identity development.

8
•
•

Ability to modify standardized tests/assessment tools and qualify conclusions
appropriately (including empirical support where available) for use with identified
groups, with consideration of their inherent cultural biases.
Conduct assessments through open-ended questions to elicit client' s perceptions
and beliefs, concepts/definitions ofhealth.

Treatment/Intervention
• Ability to use cross-cultural communication skills.
• Ability to solve problem based on client perspective.
• Can seek consultation with traditional healers or religious/spiritual leaders and
practitioners in treatment of culturally diverse clients.
• Ability to work with interpreters.
• Ability to exercise institutional skills on behalf of client; this involves out-ofoffice strategies (outreach, consultant, change agent, facilitator of indigenous
support systems) that discard the intra-psychic counseling model and view
problems/barriers as residing outside the minority client.

Let us briefly understand what the Aboriginal approach to healing is. Aboriginal
communities such as Inuit, Metis, and First Nations believe in the inter-connection among
people, the earth, and everything on it, and consequently their therapeutic interventions include
setting up healing camps close to nature (Chansonneuve, 2007; McCormick, 2000). Besides,
spiritual ceremonies of Aboriginal peoples such as sweat lodges, cedar baths, smudging, and
Qulliq lighting aim at reducing anxiety and building interpersonal trust. In addition, "seasonal
ceremonies, communal meals, potlatches, medicine walks, pow wows, feasts and giveaways ...and Inuit community celebrations are all activities that promote healing through positive
relationships" (Chansonneuve , 2007, p.37).
Chansonneuve (2007) spells out the following ten characteristics of an Aboriginal
approach to addictions:
1. An Aboriginal approach identifies and addresses the underlying causes of addictive
behaviours unique to the historical experiences of Aboriginal people in Canada.
2. The wisdom of Aboriginal cultures and spirituality is at the very heart of healing and
recovery.

9
3. The relationship among suffering, resilience, experiential knowledge, and spiritual
growth is acknowledged and honoured.
4. The interconnectedness among individuals, families, and communities is strengthened.
5. The differing pace at which individuals, families, and communities move through the
stages ofhealing is understood and respected.
6. Healing encompasses a range of traditional and contemporary activities with an equally
valued role for everyone in the circle of care.
7. Community health and community development are inseparable.
8. Culture is healing.
9. Legacy education is healing.
10. Healing is a lifelong journey of growth and change (p.60).

Practicum Site: Organizational Information
I did my practicum at the ACT office, which falls under the Mental Health and
Addictions Services ofNorthem Health (NH) in Prince George, British Columbia. The NH
multidisciplinary ACT team, with a client to staff ratio of 10:1 , delivers outreach services in
community locations and operates 7 days a week, 12 hours per day. It serves a total of 67 clients,
of whom more than fifty percent are First Nations.
NH provides ACT to complex clients who are admitted on the basis of the following
criteria (Northern Health, para 2):
•

Clients with severe and persistent mental illnesses that seriously impair their functioning
in community living (with priority given to people with schizophrenia or other psychotic
disorders) .

10
•

Clients that suffer from other issues who may benefit from a coordinated treatment
approach that includes coordination with the criminal justice system, homeless clients,
and clients with acquired brain injuries and developmental disabilities.

•

Clients with severe and persistent mental illness with significant functional impairments
as demonstrated by inability to consistently perform the range of activities of daily living
for basic adult functioning in the community, inability to maintain consistent employment
at a self-sustaining level or inability to consistently maintain a safe living situation.

•

Clients with severe and persistent mental illness who make high use of general hospital
psychiatric services, specialty hospital services, tertiary level services, or psychiatric
emergency services.

•

Clients with severe and persistent mental illness with indicators of continuous highservice needs (i.e. greater than eight hours per month).
The NH ACT team consists of:

•

Team Leader

•

Psychiatrist

• Mental Health Social Worker
• Nurses
•

Substance Abuse Specialist

•

Peer Support Worker

•

Life Skills Support Worker

• Vocational Specialist
•

Community Occupational Therapist

11

The Team Leader' s function is to collaborate on all the services that are delivered to the
clients and is responsible for overseeing the care of the clients, co-ordinating the roles and
functions on the team, and providing the "very best" services to clients. He also performs
administrative duties such as budget monitoring. Responsible to the Team Leader, all members
work together to provide flexible, community based services that are designed to promote the
stability, recovery, and community reintegration of individuals who are suffering from mental
illnesses and substance addition. This apart, mental health social workers, nurses, and substance
abuse specialists maintain caseloads and collaborate with the interdisciplinary team to provide
crisis intervention and follow-up services to clients. While the peer support worker' s typical task
lies in coordinating all services, the life skills support worker is responsible for assisting mental
health and addiction clients with services "as outlined in an individual ' s care plan, with the goal
of maximizing independent living" (Northern Health job description, 2010), and the Community
Occupational Therapist provides "psychiatric community based occupational therapy to referred
clients" (Northern Health job description, 2009).
Upon inquiry into the Continuous Quality Program, I learned that the ACT -PACT
(Provincial Advisory Committee) undertakes provincial ACT evaluations in terms of hospital
admissions for ACT clients, housing, and police contact. In other words, there is no separate
evaluation of individual ACT programs.
When asked to share overall observation on the NH ACT program, staff stated that the
program was unique since it reached out to a huge range of people including many of those who
had not accessed traditional mental health services in the past, who found themselves incapable
because of severe mental illnesses, and who were homeless and involved in criminal justice
system.

12
Practicum Learning Goals
My learning goals fall under the following four categories:
1)

ACT and Clinical Social Work Practice in a Particular Context ofNorthern Health
•

Acquiring professional clinical social work skills related to the activities of ACT social
workers.

•

Gaining a deeper understanding of ACT as a recovery-oriented service delivery model.

•

Gaining an understanding of the range of services provided to clients.

•

Gaining a comprehensive understanding of the social work values and ethics as
applicable to ACT.

•

Acquiring knowledge of most common clinical syndromes and common psychotropic
medicines.

•

Learning how social workers engage family members of clients and/or provide family
support and whether and what issues they face.

•

Learning crisis-intervention skills that are required for dealing with potential crisis
situations related to clients such as risk of suicide.

•

Gaining knowledge about the parameters social workers use in conducting assessments
and what issues or challenges they face.

•

Learning how social workers coordinate their activities with the ACT team, which
involves understanding multidisciplinary teamwork.

2)

ACT and Culturally Competent Services
•

Gaining a deeper knowledge of cultural competence in theory and practice.

•

Learning what makes ACT services at NH culturally competent.

13
•

Learning how cultural considerations are factored into intake, assessment, treatment, and
discharge.

•

Gaining an understanding how social workers on the ACT team provide culturally
competent services.

3)

ACT and Client-centred Treatment/Services/Support
•

Knowing how client's participation is ensured in the development of the
treatment/service plan and what this participation entails.

•

Gaining knowledge about the integration of theoretical aspects of anti-oppressive practice
through conducting assessments.

•
4)

Gaining conceptual knowledge about client-empowerment in respect of ACT.
ACT and the Community Setting

•

Gaining an understanding of the provision of ACT services in community locations.

•

Gaining an understanding of community resources specific to clients receiving ACT.

•

Developing skills pertinent to the community aspect of services provided by social
workers.

•

Exploring the gaps, if any, in the provision of community living or support.

Significance of the Practicum
The significance of my practicum derives from its alignment with social work values as
laid out in social work professional codes, from the theoretical framework of anti-oppressive
social work practice, and from the limitations of the mainstream treatment.

Alignment with BC program standards. BC Program Standards provide:
ACT should ensure that clients receive from all staff members effective, understandable,
and respectful care that is provided in a manner compatible with clients' cultural beliefs

14

and practices, preferred language and disability (British Columbia Ministry of Health
Services, 2008, p.45).
The primary obligation of a social worker is to maintain the best interests of the client (BCCSW,
2009, Code of Ethics section). As such, it is incumbent on him or her to adopt a holistic approach
to intervention, based on the client's preference or cultural background, rather than imposing any
mainstream treatment. As the Code of Ethics provided by the Canadian Association of Social
Workers (CASW, 2005) states, the social worker' s obligation is to respect socio-cultural
diversity and individuals' right to their "unique beliefs consistent with the rights of others" (p.4).
Moreover, social workers are expected to demonstrate cultural awareness and sensitivity by
striving to "understand culture and its function in human behaviour and society, recognizing the
strengths that exist in all cultures" (CASW, 2005, p.4). Thus, the professional code of ethics
itself provides that social workers do not neglect cultural aspects while dealing with clients.
Moreover, cultural competence is required of social workers as they work in multicultural
settings and come across clients who have a culture different from their own.
Theoretical framework. My practicum can be understood from the theoretical

perspective of anti-oppressive social work practice (Heinonen & Spearman, 2010). Though this
perspective addresses oppression suffered by the client at the individual, structural, and cultural
levels, it may be underlined that oppression operates in various domains including healthcare.
For example, imposition of treatment on a client, without considering his or her cultural needs,
constitutes oppression. In the words ofCamiol (1992): " [social workers] place their professional
power at the disposal of clients in an explicit and conscious manner. They seek to share their
limited power and to promote a client-worker relationship based on mutual dialogue rather than a

15
top-down interaction" (p.9). Thus, cultural competence is one of the applications of antioppressive social work practice. Philips et al. (2001) point out:
... some consumer groups believe that it [ACT] is a mechanism for exerting social control
over individuals who have a mental illness, particularly through the use of medications;
that it can be coercive; that it is paternalistic; and that it may foster dependency. (p.777)
From the perspective of anti-oppressive practice that emphasizes client empowerment,
collaboration between therapist and client in determining goals and choosing intervention is
considered critical to cultural competence (Hays, 2001; Lo & Fung, 2003; Sue & Sue, 2003;
Tsang, 2003). Moreover, cultural competence is associated with client empowerment which is a
stated component of ACT as per the BC Program Standards. Further, as per the holistic
definition of mental health, provided by the Canadian Mental Health Association:
Mental health is the capacity of the individual, the group and the environment to interact
with one another in ways that promote subjective well-being, the optimal development
and use of mental abilities (cognitive, affective and relational), the achievement of
individual and collective goals consistent with justice and the attainment and preservation
of conditions of fundamental equality. (Definition of mental health section)
The above definition suggests that well-being of the people with mental illnesses should be
considered in the context of inter-personal relationships, community, and society. Thus, ACT
which involves community living falls inevitably within the framework of a critical antioppressive practice approach which seeks empowerment of clients in contrast to coercing them
and imposing interventions on them.
As for my future practice, it will be important for me to check any subconscious or
unconscious, unintended, and inadvertent coercive practices in dealing with clients. Thus, the

16
words "client-centred" and "individualized" in the context of the ACT model and anti-oppressive
practice hold special significance for me.

Aboriginal clients and limitations of mainstream treatment. Facts indicate that there is a
high incidence of substance abuse among Aboriginals. "Alcohol-related deaths are 43 .7 per
100,000 for Aboriginal people, compared with 23.6 per 100,000 for the general population"
(Menzies, 2004, p.456). According to the National Aboriginal Health Organization (2011), "the
use of illicit drugs is a serious problem among First Nations, Inuit and Metis. In 2002-2003
26.7% of First Nation adults used marijuana, compared to 14.1% in the Canadian population"
(para.1 ). Tracing colonial roots to the alcohol addiction among Aboriginal people, Chansonneuve
(2007) states: "The origins of alcohol abuse can be found in early Canadian history with the
introduction ofliquor by European fur traders in the early seventeenth century" (p. 7). In the
report to the Aboriginal Healing Foundation he points to the following gaps in intervention
involving northern communities or Aboriginal addicts:
•

A full range of services for the North from detoxification and treatment to continuing
care programs staffed by qualified Inuktitut-speaking Inuit.

•

Education and prevention resource materials available in Inuktitut.

•

Pre-care services for Aboriginal youth that provide a safe place to withdraw from alcohol
and/or detoxification and treatment services for Aboriginal women and their children.

•

Cross-training for staff in an Aboriginal approach to addiction and mental illness
(Chansonneuve, 2007, 73-74).
McCormick (2000) shares another perspective regarding cultural specificity of

Aboriginals which poses a challenge to mainstream service providers: "One obstacle is that for

17

traditional Aboriginal people it can be very shameful and embarrassing to admit having problems
of drug and alcohol abuse. This can prevent them from seeking help" (p.26).
Thus, there can be a missing component of a culture-specific approach which includes
provision of culturally sensitive programs for Aboriginals, including their language and
approaches to addiction treatment. In contrast, ACT is known for individualized service plans
that call for culturally competent services. In my placement with the NH ACT Team, I was able
to practice and reflect on these ideas.
In the next chapter I will provide a summary of the literature that relates to my practicum
objectives.

18
Chapter 2
Literature Review
This review ofliterature revolves around the following key terms that are associated with
my practicum: cultural competence, ACT, Aboriginal clients suffering from substance abuse and
mental illness, and healthcare providers.
Research in the area of cultural competence has largely been conducted in the following
contexts: exploration and examination of cultural barriers faced by Aboriginal clients in
accessing healthcare services; perceptions and experiences of Aboriginal clients in respect of
culturally competent interventions; and evaluation of effectiveness of culturally competent
interventions, including ACT. Before I review these studies, it is important to underline that in
contrast to service users, research on cultural competence has not been found to be conducted in
the exclusive domain of cultural competence of ACT providers and the barriers they face.
The existing literature can be reviewed under the following sections:
1.

Cultural Competence and Healthcare for Ethnic Minorities
Cultural competence in healthcare is being increasingly recognized as a vital strategy to

address racial and ethnic disparities. Betancourt, Green and Carrillo (2002) conclude cultural
competence in healthcare systems demonstrates the ability of the latter to provide care to clients
with diverse cultural values and beliefs. Anderson et al (2003) reviewed five interventions to
improve the cultural competence of health care systems:
i) Programs to recruit and retain staff reflecting cultural diversity of the community served.
ii) Use of interpreter services for clients with limited English proficiency.
iii) Cultural competence training for healthcare worker.
iv) Use oflinguistically and culturally appropriate health education material.

19
v) Culturally specific health care settings.
"For each intervention reviewed, the outcome measures evaluated to determine their
success were client satisfaction with care, racial or ethnic differentials in utilization of health
services or in received or recommended treatment, and improvements in health status measures"
(Anderson et al. , 2003 , p.72). The researchers point out that they could not determine
effectiveness ofthese interventions because of few comparative studies. Other scholars have
produced studies demonstrating how an awareness of a medical professional ' s own cultural
values and beliefs is critical to cultural competence (Gompertz, 1997; Williams, 2001).
Gompertz (1997) also spells out the socio-cultural elements associated with racial and ethnic
minority clients, which healthcare providers should take into consideration: culture-related
syndromes, idioms of distress, socio-political functioning, and acculturation processes. Dell, Dell
and Hopkins (2005) provide evaluation of holistic inhalant abuse treatment to First Nations
youth and suggest social, psychological, and spiritual environments for recovery as part of
resiliency.
From the perspective of anti-oppressive practice that emphasizes client empowerment,
collaboration between therapist and client in determining goals and choosing intervention is
considered critical to cultural competence (Hays, 2001 ; Lo & Fung, 2003; Sue & Sue, 2003 ;
Tsang, 2003). In contrast, aiming to understand cultural competency comprehensively, Lo and
Fung (2003) examined its generic and specific aspects in psychotherapy and spelled out the
following phases: pre-engagement, engagement, assessment/feedback, treatment/intervention,
and closure/discharge. In other words, cultural competence in healthcare is a complete process
that begins prior to the phase in which the healthcare provider engages with the client. This is a
major strength of their work.

20
The above studies, however, neglect research into cultural competence of service
providers.
2.

Barriers Faced by Service Users and Their Perceptions and Experiences
Under this segment, studies have focused on the barriers faced by culturally diverse

clients in accessing healthcare services or utilizing them adequately, which underscores the need
for cultural competence. Studies that bring out ethnically diverse clients' perceptions about
mainstream treatment have also been analyzed in this section.
Cook, Omofolasade, and O' Brien (2005) document experiences of minority service users
and their perceptions about cultural competence ofhealthcare providers. This study is
particularly useful as the majority of minority service users were reported to be satisfied with
healthcare in Omaha. This study can be a base for further research into factors of minority users '
satisfaction vis-a-vis the mainstream health system. McCormick (1996) records experiences of
the First Nations people of British Columbia in the context of culturally appropriate counselling,
underscoring the importance of cultural competence. Similarly, Johnstone and Kanitsaki (2006)
underline that on account of failure of health care providers to understand socio-cultural
differences between themselves and their clients, communication and trust between them may be
adversely affected, which in tum may affect quality of care received by clients. Other such
studies have been conducted by Bischoff (2003) and Kelly and Bancroft (2007). In particular,
Bischoff (2003) highlights the following problems emanating from consultations that are not
culturally competent:
•

Addressing clients' needs completely.

•

Providing proper explanations.

•

Showing respect during the consultation process.

21
•

Giving follow-up information.
Though the limitation of the above studies is the sole focus on miscommunication as a

barrier in receiving effective healthcare, they can add or contribute to healthcare providers'
understanding of the importance of culture as a component of communication in healthcare.
Besides, their fmdings can be applicable in the context of diverse ethnic minority clients.
Highlighting a different barrier, Kurtz, Nyber, Tillart, and Mills (2008) find that many
First Nations and Inuit people feel it is not safe to access health care as they feel marginalized and
have experienced oppression and racism within the health care domain. Women who participated
in this study "talked about feeling judged and discriminated against simply because they are
Aboriginal" (Kurtz et al, 2008, p. 57). This study was significant from the point of view of
illuminating racism experienced by Aboriginals, revealing Aboriginal people' s perceptions about
the mainstream health care system, and highlighting the stories of Aboriginal women in
particular. As such, the combined issue of gender and racism was illuminated in this study.
Clearly, the necessity of cultural competence emerges from these findings. As regards
perceptions of culturally diverse service users, Attagutsiaq, Joamie, Pitseolak, Ootoova, and
Ijjangiaq (2001) highlight perceptions of Intuit elders about traditional health in contrast to
mainstream treatment.
The above studies, however, do not take into account perceptions ofhealthcare providers
in respect of delivering culturally competent services. But my practicum takes into account
opinions and experiences of the ACT team in the context of cultural competence, which have
been documented in this report in the next chapter.
3. Examination ofEffectiveness of Cultural Competence ofHealthcare Systems and Integration
of Traditional Healing and Mainstream Treatment:

22
Incorporation of traditional healing and other theoretical approaches can result in good
outcomes in terms of recovery and client satisfaction (Duran, 2006; Hill & Coady, 2003;
McCormick, 2000; McCormick, 2005; Menzies, Bodnar & Harper, 2010). Studies have been
conducted establishing linkages between the lack of cultural competence and such problems as
incomplete assessments, incorrect diagnoses, and inappropriate treatment (Kirmayer, Groleau,
Jaswant, Blake, & Jarvis, 2003, p. 153), because ofwhich Aboriginal people tend not to use
mainstream health services. The strength of these studies lies in highlighting the importance of
traditional healing which should be integrated with mainstream treatment, given clients'
preference.
Illuminating power relations as a factor in cultural safety, Clark et al. (2010) discuss the
power relations within the health care worker and client relationships. They state that health care
workers should show respect for cultural taboos and form a multidisciplinary team. In this
regard, it is apt to mention that the ACT team-the focus of this practicum-is multidisciplinary
and, thus, contributes to serving clients by avoiding any rigid or particular perspective. For
example, social workers, groomed in social work philosophy of person-centred treatment, add
diversity to the team. Similarly, Anderson and Smylie (2009) evaluate health systems in Canada
in terms of their performance in the context of First Nations, Metis, and Inuit clients and offer
recommendations for further upgrading the system to better meet the needs of indigenous people.
In a slightly different arena, Am' arnaaq (20 10) explores the place of health of Aboriginal
Peoples within the health sciences.
In fact, a key theme running in the literature on cultural competence vis-a-vis Aboriginals
in the context of integration of both traditional and mainstream models is the recognition of
intergenerational trauma suffered by Aboriginals because of colonization. Menzies (2004) points

23
to the growing evidence that substance use among Aboriginals could be attributed to broader
systemic issues, that is, their colonization in the past. Carvajal and Young (2009) write:
"Research shows an association between the effects of cultural dislocation, unresolved grief,
depression, and low self-esteem with drug and alcohol misuse among Aboriginal groups in North
America" (p. 211). Similarly, Chansonneuve (2005) documents cases in support of reclamation
of connection with nature and other aspects of indigenous healing in assisting Aboriginal people
with overcoming residential school trauma. Fletcher and Denham (2008) on their part provide a
Nunawat case study based on their research into historical trauma, which suggest a move toward
Aboriginal healing.
Chansonneuve (2007) explains that traditional Aboriginal teachings are especially
important to addictions and trauma recovery because they have the potency to offset what was
imparted to Aboriginal children at residential schools (they were taught that they were "savage
and incapable of responsibility") by nurturing "self-respect, self-care, and self-responsibility; and
respect and responsibility for the family, the community, the nation, and the environment"
(p.42). Hylton (2002) puts it in these words:
Healing, in Aboriginal terms, refers to personal and societal recovery from the lasting
effects of oppression and systemic racism experienced over generations. Many
Aboriginal people are suffering not simply from specific diseases and social problems,
but also from a depression of spirit resulting from 200 or more years of damage to their
cultures, languages, identities and self-respect. (Appendix C 5)
Similarly, Robbins and Dewar (2011) provide an account of application oflndigenous healing to
Aboriginal communities toward their recovery from intergenerational pain. They advocate that
future policy development and implementation support Indigenous peoples and communities in

24

maintaining and building upon the knowledge amassed by their ancestors. As such, the cultural
component is required to boost Aboriginals' self-esteem, whereas mainstream treatment does not
take cultural needs into account (Blue & Darou, 2005; McCabe, 2007; Mohatt et al., 2008;
Spicer, 2001).
Works have also appeared that explain the decline of Aboriginal healing in Canada
because of colonization. In this regard, Deiter and Ottway (200 1) point out that Aboriginal
people perished after colonization as their population in North America went down to a fraction
of 90 to 112 million. Mainstream health policies and services came to exclude traditional
healing, exhibiting cultural insensitivity (Browne, & Smye, 2002).
The strength of the above studies in relation to substance abuse among Aboriginals is that
they sought to locate the causes of addiction in societal structure and its institutions, tracing them
to the colonial period. Hence, recovery has been linked to bolstering of self-esteem by
connecting the Aboriginal clients with their culture and with their traditional healing practices. It
may, however, be mentioned that not all Aboriginal clients might be addicts because of trauma
resulting from colonial policies. Hence, client preference for the treatment should be ascertained
rather than inclining toward a treatment model merely on the basis of research.
Finally, there exists literature that features research findings that support culture as a key
determinant ofhealth for Aboriginal people, for example recovery of First Nations, Inuit, and
Metis women from illicit drug use (Niccols, Dell, & Clarke, 201 0).
More culturally-sensitive research needs to be undertaken in this field in order to enable
social workers to replicate success stories where possible. As Martin-Hill (2009) points out, there
is an existing research gap between the community practice of traditional healing and the number
of related cases available for review.

25
4. ACT and the Cultural Factor
Yang et al. (2005) through their research findings conclude that the ACT specifically
designed for culturally diverse clients is effective in preventing relapse. On the other hand, Chow
et al. (201 0) highlight innovations and adaptations required for a culturally competent assertive
community treatment team for severe and persistently mentally ill clients. In this regard, they
suggest incorporation of the Multi-Family Psycho-education Group (MFPG) to an ACT Team.
These studies indicate that ACT does not operate in a vacuum; program Standards are at best the
guide, but the ground reality of diversity of clients and the nature of the clients' circumstances in
life determine how ACT needs to be designed.
5. ACT and Related Issues
In a slightly different vein, Philips et al. (200 1) highlight important issues that arise in the
implementation of the ACT model, viz., a clear concept ofthe model's goals and treatment
principles, safety of team members in the community, cultural competency, and professional
boundaries in community locations. Cooley (2012) in the exploratory qualitative study on the
perceptions ofthe social worker' s role in ACT teams spells out the following four themes:
interpretation of the social worker role; role clarification of the different ACT team members;
overlapping roles of the ACT team members; and actions to help role clarification. Thus, proper
implementation of ACT also needs a clear delineation ofthe role of the social worker in
conjunction with coordination of his or her activities with the overall ACT functions.
This apart, there is literature on various aspects of ACT in connection with mental illness
and substance abuse, for example, studies by McGrew and Wilson (2002), McFarlane (1997),
Santos et al. ( 1993 ), Drake et al. ( 1998), Bond et al. (1991 ). But they do not have a cultural
component as part of effective health care services.

26
This review has enlightened me considerably in terms of the importance of clientcentricity and cultural competence, especially for Northern social work practice.
In the next chapter I will describe the specific activities and tasks I performed as well as
the practical learning that occurred.

27
Chapter 3
Activities, Tasks, and Learning

In this section, I have provided a summary of what I did and learned in terms of activities
and specific tasks toward achieving my learning goals as stated in chapter one. This is followed
by the description of the outcomes or my learning gains. At the end, I have detailed my
experiences in respect of the ACT program ofNorthcoast Behavioral Healthcare System
(NBHS), Ohio, U.S.A.
Activities
Assessment and charting. I spent the first three weeks of my practicum orientating

myself with the ACT policy and procedures, receiving training using SYNAPSE which is an
electronic database for documenting client' s assessment and daily activities, and going out with
the ACT team to deliver, administer, and monitor medication to clients and engage the clients
socially.
It may be mentioned that the day at the ACT office begins with the Daily Task Meeting

at which the team leader assigns the morning tasks to the team such as administering injections
and medications, and social engagement with clients. Once I learned how to administer and
monitor medications, my supervisor gave me the opportunity to undertake this task
independently. Subsequently, my supervisor assigned me a client whose primary care
coordinator was on leave. It was a great experience to learn about initial intake procedure and
develop treatment care and weekly service plans for clients.
This apart, I learned how to conduct risk assessment and suicide assessment. I prepared a
no-suicide contract for a client who was suicidal. In conducting assessments, social workers
involve families as well. So, I contacted a client' s parents to learn about the level of financial

28
support they provide to their son and if they were handing him cash, since the client had a history
of substance abuse. Importantly, I learned how to conduct mental health assessments. For this, I
reviewed a mental status checklist, and entered information about clients' behaviour, speech
pattern, mood, and symptoms into SYNAPSE. Also, I learned how to diagnose mental disorders
using the Diagnostic and Statistical Manual ofMental Disorders (DSM-IV-TR). For getting
further insights into the diagnosis process, I interacted with the ACT team, watched videos, and
read clients' files. For instance, I had a meeting with a psychiatrist to discuss the case of a couple
who were suffering from schizophrenia, and the woman had been reported to be physically
assaulting her partner. We came up with solutions such as group counselling and therapy.
I became acquainted with commonly used abbreviations and symbols for charting such as
AC (before meals), ADL (activities of daily living), bid (twice daily), C& S (culture and
sensitivity), drsg (dressing), and FBS (fasting blood sugar). I also became familiar with the
terminology for charting. For example, to describe the client mood, there are such terms as
agitated, elated, euthymic ("mood is normal appropriately reflective of situation(s) of days
events"), stable, and hypomanic ("a distinct period during which there is an abnormally and
persistently elevated, expansive or irritable mood lasting at least four days but somewhat less
intense than in mania"), whereas affect can be described as animated, blunted, fatigued, flat, or
gnmacmg.
This apart, I learned how assessments could require intangible skills such as patience and
flexibility of responses on the part of social workers. In this regard, I liked how the staff told me
that it could be challenging if the client is not assisting with completing the comprehensive
assessment. In that case, they exhibit patience in getting it completed and also refrains from
using the word "assessment" since it could sound clinical to that client.

29

Reaching out to clients. I accompanied the ACT team in engaging clients in gardening,

taking them to the Activity Center for Empowerment (ACE), taking them to coffee socials, going
to their home, and checking their blister packs. Further, I accompanied clients to places such as
the YMCA gym, Bear Lake outing, and restaurants for celebrating their birthdays. Such
engagements also provide social workers with an opportunity to informally observe client
behaviour for his or her mental health assessment. This apart, I attended the Homelessness
Intervention Project (HIP) meetings. HIP is a gathering of multiple agencies that provide services
typically to those who are not housed. It is an occasion for such agencies to connect with their
clients as well as providing front line services to needy individuals by avoiding waitlists and red
tape.
In order to make clients learn life skills and become independent in their activities of
daily living, there are such practices as provision of ACE meal tickets that are given to clients
who clean up their houses and come for injections. It is a sort of encouragement and reward for
them to perform the work assigned to them.
I also worked with a client on anger management by knowing her problem and concerns.
I gave her some homework to be followed up by her meeting with me. I also learned how money
management for a client could be an important task for the team. In this regard, client's spending
of money on drugs can be an issue. Therefore, in one case, we divided the client's use of money
into four weeks, since he had used up his monthly allowance on drugs within a few days. Such
issues present cases of conflict between client interest and what the client desires and require an
appropriate response from the team. Thus, the practicum revealed cases when clients' right to
self-determination and the service team's response may be mutually conflicting, but there are

30
exceptions when the client's life is in danger and his or her choices cannot go completely
unchallenged by treatment providers.
Active participation in interdisciplinary team meetings.
1. Community Rounds: Community rounds take place every two weeks. They basically involve

provision of mental health and addictions services, forensic psychiatric services, and
correctional services. It is ensured that clients are connected with at least one of these
agencies.
2. Staff Meeting: Staff meetings take place every second week, enabling the ACT team
members to discuss operational issues.
3. Kardex Meeting: Every second week, the entire staff goes through all the cases to discuss and
resolve clients' specific concerns. It is an opportunity for the whole team to collaborate on
providing effective treatment. It is also a chance for the primary care coordinator and its mini
team to have discussions on clarification of treatment goals and the tasks associated with
achieving those goals. And on every alternative week the team undertakes a reflective
practice-each primary worker identifies one client and has a more intensive reflective
meeting with the mini team and the rest of team for a better coordination.
Gaining knowledge about most common clinical syndromes and most common
psychotropic medicines. It is apt to mention the BC Program Standards guideline here: "All

ACT team members shall assess and document the client' s mental illness symptoms and
behaviour in response to medication and shall monitor for medication side effects" (British
Columbia Ministry of Health Services, 2008, p.34).
I went through clients' files to find out what they were diagnosed with, almost all of
whom were found to be suffering from schizophrenia. Then, I read about schizophrenia and

31

other clinical syndromes such as bi-polar disorder and personality disorder. For example,
schizophrenia' s symptoms are both negative and positive. Positive symptoms include
hallucinations, delusions, grandiosity, thought disorder, and disorganized speech and
behaviour. Negative symptoms include blunted affect, emotional and social withdrawal, weak
concentration, lack of motivation, and passivity.
Also, I reviewed clients' medical binders to learn what psycho-tropic medications they
were on. I also read a book titled Psychotropic Agents (2010) edited by Burgmann, Magee,
Remck, and Thompson, as suggested by my academic supervisor, which is an excellent source
on medications and their side effects. Besides, I attended workshops to acquire knowledge
about medications such as Latuda and Gen-Clozapine that are used to treat schizophrenia, as
well as attending an extremely useful course titled "Social Work in Mental Health" at the
university. Further, I interacted with the nurses on the ACT team to acquire first-hand
knowledge of medications and their side effects.
The following tables serve as an example of my familiarity with medications and the
syndromes they address.
Medication Group
Antipsychotic Agents

Description
Alleviate psychosis found in psychiatric disorders
such as Schizophrenia, Substance-induced Psychotic
Disorders and Delusional Disorders

Antiparkinsonian Agents

Treat the extrapyramidal side effects of antipsychotic
medications including akinesia (weakness) and
akathisia (restlessness)

Antidepressant Agents

Treat disorders including Depressive Disorders,

32
Bipolar Disorder and Obsessive Compulsive Disorder
Mood Stabilizers

Treat Bipolar Disorder and Schizoaffective Disorder
in order to prevent acute depressive episodes

Antianxiety and Sedative-Hypnotic

Treat anxiety and insomnia

Agents

Treatment

Medications
Clozapine, and Quetiapine

Symptoms of schizophrenia in patients who have not
benefited from other medications

Lithium Carbonate

A mood stabilizer, it treats Mania in people with
Bipolar Disorder

Zoplicane

Sleeping problems

Lorazepam (Ativan), and

Anxiety

Buspirone
Lamotrigine, and Carbamazepine

Seizures in patients who have epilepsy. Lamotrigine is
also a mood stabilizer

Benztropine

Parkinson's disease

Escitalopram

Depression

Critical incident stress debriefing. I also became familiar with Critical Incident Stress
Debriefing (CISD) when I attended a session addressed by a psychologist at the ACT office. It
took place in the aftermath of a violent incident by a client at the ACT office where I did my
practicum.

33
CISD is a process designed to mitigate the impact of a critical incident which is defined
as "any situation faced by employees that causes them to experience unusually strong emotional
reactions and that has the potential to interfere with their ability to function" (Northern HealthWorkplace Health & Safety, p.l). In the interest of patient care as well as their own
psychological health, social workers should be able to respond expeditiously in the wake of a
critical incident such as suicide or attempted suicide of a patient or an act of violence toward a
staff member. The responses include providing emotional support to traumatized employees, and
contacting the appropriate organization such as Northern Health' s Employee and Family
Assistance Program.
I think a social worker or any other professional must be conversant with appropriate
responses to such critical situations that may occur at a workplace.
Visiting different program/sites ofNH. I visited Nechako Centre and its Adult Day
Treatment Program, Adult Detox, Youth Detox, Methadone Program, Eating Disorder Clinic,
Early Psychosis Intervention, and Elderly Services Program. Further, I visited Community Acute
Stabilization Team (CAST) that provides integrated Mental Health and Addictions services to
adults who are over 19 years of age and present with a variety of mental health and addictions
disorders as per DSM IV (Axis I and II) criteria. The varying diagnoses may include Personality
Disorders, Mood Disorders, Bi-Polar Disorders, Obsessive Compulsive Disorder, Post Traumatic
Stress Disorder, and Post-Partum Depression. In addition, I visited the Community Outreach and
Assertive Service Team (COAST), which is a multidisciplinary team including a Social Worker,
Nurses, Life-skill worker, and provides ongoing support for clients with persistent mental illness.
Moreover, I visited the Community Response Unit (CRU) that is an entry point for any

34
individual seeking access to mental health and addictions programs. This multi-disciplinary team
basically does the client intake and assessment, and facilitates referrals to appropriate services.
These visits were important for me to understand the functioning of these programs, their
objectives, and services provided by them as well as their referral processes to facilitate clients'
referral to these organizations.
Specific Tasks

•

Interactions with individual members of the ACT team: These interactions were aimed at
learning about members' specific roles, delivery of client-centric and culturally
competent services, and about the issues and challenges involved.

•

Understanding NH and NBHS policies, programs and procedures in relation to ACT and
culturally competent services: I collected and reviewed material that could aid my
comprehensive understanding of ACT as a recovery-oriented model in its manifold
aspects. In this regard, I reviewed the pertinent material such as decision support tools, as
listed on the Prince George ACT Peer Review Document under the following sections:
Target Population and Admission Process, Structural and Functional Processes, External
and Community Relations, and Administrative Organization.

•

Discussion with the social workers: Client-centric and culturally competent services were
among the key aspects of my discussion with ACT social workers. The related questions
have been provided in the Appendix section.

•

Research: I supplemented my practicum by conducting research into ACT's association
with clinical social work practice, cultural competence of ACT services, and clientcentric services, including psychosocial rehabilitation principles.

35
•

Visit to the Department of Aboriginal Health: I visited the Department of Aboriginal
Health at Northern Health to gain knowledge about Aboriginal Health and the related
client-centered services.

Practical Learning
ACT procedures, client-centric services, and social worker role. At the outset, I will
describe the role and values associated with social workers on the ACT team.
Social Worker on the ACT Team. The role of social workers on the ACT team consists in
providing community based services for the stability, recovery, and community reintegration of
clients who are suffering from mental illnesses and substance addictions. In this regard, their
activities include conducting psycho-social and mental health assessments, entering into liaison
with community partners, and identifying community resources. The NH document on job
description spells out the following typical duties and responsibilities of a social worker:
•

Provides immediate face-to-face intervention as required in response to client needs.

•

Lead the team in engagement with the family members of clients and/or their natural
supports in the treatment/service planning process.

•

Leads the team in individual and/or multiple family support and therapy.

•

Provides leadership to the team with respect to the entitlements, (e.g., financial, housing),
advocacy.

•

Provides crisis intervention and brief therapy services as needed.

•

Consults with other professionals as needed.

•

Provides information and educational materials to assist the individual and their
identified supports to make informed decisions, and to access available resources.

36
•

Provides leadership in building Mental Health and Addiction Services connections across
the continuum of services.

•

Collaborate with client in the formulation of a comprehensive service plan that is
reviewed and modified with client on a regular basis.

•

Provides outreach, case management, counseling, advocacy, and other needed services to
clients in any environment including: the streets, shelters, prisons, hospitals, apartments,
office, etc.

•

Provides individually tailored services to each client based on psychosocial rehabilitation
principles.

•

Maintain written and computerized records, compile reports and complete other program
documentation (including case notes, statistics, letters, psychological evaluations, etc.).

•

Organize and participate in social activities with clients in the community.

•

Coordinate and monitor referrals to community services, and advocate client participation
in them.

•

Leads groups, workshops, and in-services on topics such as substance abuse, safe sex,
domestic violence, harm reduction and relapse prevention.

•

Participate in on call rotation.

•

Perform comprehensive mental health assessments of all clients.

•

Cross train team members.

•

Provide individual counseling/support to clients.

•

In collaboration with other team members, develops policies and procedures.

•

Attends and participates in team meetings.

•

Maintains personal professional development.

37
•

Performs related work as assigned.

Values and skills. Registered with the BC College of Social Workers (BCCSW), the ACT
social workers at Northern Health are required to adhere to BCCSW guidelines in terms of social
work ethics and values. When asked for a comment in this regard, the staff pointed out that since
social workers work at a micro level, they are constrained in advocating change for overall social
welfare, but micro changes impact the "big picture." For example, one of the team members
liaises within the community where change trickles down to the front line. Other values the ACT
social workers employ are beneficence and nonmaleficence. Furthermore, they are expected to
act according to the organizational values and requirements.
It is pertinent to list the skills/aptitudes necessary for success as a social worker for ACT.

In this regard, the staff highlighted the following ones: independence, excellent judgement,
troubleshooting capabilities, readiness to work with the unknown, aligning one's actions with
treatment plans in the best interest of the client, crisis intervention, mental health assessment
skills, and an appropriate response to a client's suicidal attempts.
I gained some of these skills during the practicum, as explained in my activities above.
But I understand that it takes time and experience for a worker to become adept in the required
skills, whereas soft skills such as sound judgment demand continuous learning. I also learned
about the challenges involved. For example, the staff shared that the biggest challenge one
encountered upon first joining an ACT team lay in not knowing the baseline, especially when
one has 60 baselines to learn.
It is important to elaborate on the crisis intervention skills that I learned. The advantage

of an ACT team in terms of crisis intervention is that the team has people from different
disciplines who can come up with required responses, depending on the situation. The examples

38
include provision of medical help, admission to hospital, and provision of emotional support.
Further, the staff explained that though the first step in crisis intervention is to determine what is
going on and then make the appropriate referral, it is important to respond according to the level
of crisis, which can demand utilizing resources such as Davis Drive or hospital or contacting
nursing staff for medications.
This apart, I learned that if clients are functioning below their baselines, this constitutes
the crisis situation. In this regard, staff stated that understanding their baseline is the first part,
which demands dealing with the potential crisis situation involving recording, recognizing,
observing and monitoring. For example, if a person is kicked out of the house, it constitutes a
housing crisis. In that case, the team member will work with the client to formulate a short-term
plan and a medium plan as well as finding a long-term solution. Thus, problems are broken up
into smaller pieces in order to meet the basic needs first.
Discussion with the staff further clarified that crisis intervention skills involve assessing
the client, knowing the baseline, and identifying the risk factors from clients' past history.

Engaging families. Social workers encourage family members/supports of clients to
work with the team around the client's care. In this regard, staff suggested that after meeting the
clients, one should always get their permission to contact natural supports such as families since
the latter know the clients best. The staff, however, added an important caveat that one should
strike a balance between sharing too much information with families and involving them in
treatment planning. One of the ways the ACT staff engage families is to take them out for lunch,
which also fosters connection between clients and their families.
When asked about the issues faced in involving families, the staff informed that there
were largely no issues and that families were usually positive on inclusion in treatment plans. If I

39
allude to my experiences in India, families exhibit much interest in being involved at every stage
of treatment, beginning with the client' s admission. This nature of involvement is sometimes
challenging for healthcare providers since they are faced with consistent queries and also need to
assuage anxieties of families . Thus, depending on the case and the region, the social worker
should be able to work with different sorts of families, for example, anxious parents, agitated
siblings, or even passive guardians who just wait and watch.

Working with other ACT members. In documenting a mental health assessment, the
social worker may want to seek assistance of a nurse and attend psychiatric appointments with
the client. For example, the staff informed that nurses are contacted in order to know as to what
symptoms specific medications are meant to address and in case they are not addressed, the issue
is brought to the nurses' attention and documented in SYNAPSE. Similarly, since social workers
do not prescribe medications, they have the option to attend psychiatric appointments with
clients so that they can voice their own concerns and get some more support and education from
doctors.
In regards to coordination among team members, I learned that the team leader makes
sure that they meet every day for planning and coordination of tasks. This apart, there is an
informal peer review process for members ' adherence to the BC Standards.

ACT procedures, and client-centric services. This section explains my learning gains in
terms of my understanding of ACT in conjunction with its client-centricity. Apart from the
associated procedural aspects, statements of team members have been included.

Referral. Agencies such as Community Response Unit (CRU) refer clients by completing
a referral form and submitting it to the ACT Program Team Leader for review. The form
contains the client' s personal information as well as information pertaining to his or her medical

40
information/previous treatment, legal history, housing history, addictions/substance use, and risk
assessment and service requirements. The admission criteria are based on the Program Standards
for ACT Teams in British Columbia (as spelled out in chapter one).

Camberwell Assessment ofNeed- Clinical version (CAN-C). The Team Leader presents
the client to the team at the team meeting and assigns him or her to a Primary Care Coordinator
(PCC). The PCC enters the following information in SYNAPSE: a) enrollment; b) HoNOs; c)
Diagnosis; and d) MRR, as well as Intake Package of Consents which consists of such elements
as limits of confidentiality; consent to "obtain and release information"; and patient consent to
access PharmaNet. The PCC then records the information pertaining to the client Face/Cover
Sheet which has such components as Name, Date of Birth and Casebook#, Date of Current plan,
Recovery Plan Number, and DSM IV Diagnoses. It is pertinent to mention the NH Policy
Statement on Client-centric Initial Intake:
The ACT team will conduct an initial client-centered assessment with each new client
that is admitted and has consented to receive program services. The initial assessment is
the first step in the individualized treatment/service planning process and will begin to
formulate and prioritize the current issues as identified by the client.
The PCC then completes the Camberwell Assessment ofNeed- Clinical version (CAN-C) by
working with the client. "The Camberwell Assessment of Need (CAN) is a tool for assessing the
needs of people with severe and enduring mental illness" (Slade, Thomicoft, Loftus, Phelan, &
Wykes, 1999, p.l). It consists of22 domains oflife such as accommodation, food, physical
health, psychotic symptoms, and money. Its purpose is to ascertain client strengths and selfstated goals, build therapeutic relationships with the client and the family, and make diagnoses of
psychiatric and physical health issues. It may be added that client strengths are identified by

41
using the ROPES (Resources, Options, Possibilities, Exceptions, and Solutions) Document.
Moreover, such comprehensive client-centric assessment reflects cultural considerations since
client-specific strengths as well as the domains oflife, as stated above, issue from their cultural
specificities as well. In other words, NH' s culturally competent services reflect even in the initial
stage of a client' s interaction with the team.

Recovery plan. Afterwards, the PCC schedules a recovery planning meeting to develop
the Recovery Plan which involves using the "client' s self-stated unmet needs (from CAN-C) and
discussing with the client to prioritize focus areas" : functioning in daily life; housing; work
and/or school; interpersonal and family; mental health problems/symptom management; physical
health/wellness; legal; and other. The team also conducts a risk assessment. At the staff meeting,
the entire team gives inputs on this recovery plan, and revisions are shared with the client. The
final recovery plan is placed in the recovery plan binder with the Face Sheet. To work on the
plan, the client and PCC prepare a Client Weekly Schedule. Clearly, the NH ACT recovery
planning process is client-centric, which is in contrast to the treatment plans that are imposed by
healthcare providers and clients have either no voice or are neglected, as discussed in the
literature review section. Such situations are worsened when there are cultural differences
between the client and the practitioner, and thus, the latter fails to understand the needs of the
client that may emanate from the client's cultural upbringing, such as preference for traditional
healing. Hence, the NH ACT model comes across as an antidote to client-disempowering
practices.

42

Strengths

I

Client and PCC make
Client Weekly Schedule
according to the Final
recovery plan

Revise and share with
the cl ient

The weekly schedule is
used to make the daily
task sheet

Task are assigned at the
Daily Task Meeting

ReAssess goals in 6
months

Figure 2: Recovery Planning Process (Summary of the above steps has been provided in the
Appendix section)

Description of Comprehensive Assessments. Comprehensive Assessments have been
categorized as follows:
• Psychiatric History, mental Status, and Diagnosis (Psychiatrist)
• Physical Health (Nursing Assessment)
• Use of Drugs or Alcohol (A&D Assessment)
• Education and Employment (Vocational Rehabilitation Assessment)
• Social Development and Functioning (Social Work or Mental Health)
• Activities of Daily Living (Occupational Therapist Assessment)
• Family and Relationships (Social Work or Mental Health Clinician)
It may be added here that not all assessments are done on paper; there is also a visual

assessment that includes clients' mental and physical health and their everyday living skills.

43
Procedure:
a) The comprehensive assessments will be completed within one month after the client's
admission.
b) The service coordinator will present the results of the comprehensive assessments at the
treatment plan meeting where all the team members who have been assigned direct care with
the client will be present.
c) The service coordinator is directly responsible to ensure that the client is directly involved
with the treatment plan.
d) The service coordinator will ensure the client consents to any involvement of other agencies
and social supports in the treatment plan. (Shoemaker, 201 0)
Furthermore, according to the NH policy statement:
The ACT team will develop a collaborative, client-centred treatment plan with his/her
appropriate supports. The comprehensive assessments will guide the development of the
individualized treatment plan. As per the ACT standards, the treatment plan shall:
a) Identify individual strengths/issues
b) Set specific short-term and long-term goals for each strength/issue
c) Establish the specific approaches and interventions necessary for the client to meet
his or her goals, improve his or her capacity to function as independently as possible
in the community, and achieve the maximum level of recovery possible.
It may be added that the treatment plan is based on the client's consent to the services the client

wants-the services provided by the ACT team are:
•

Comprehensive and multi-disciplinary mental health services.

•

Transportation to various activities, appointments and services.

44
•

Medication monitoring and administration by ACT.

•

Photos for identification purposes, during outings, and activities offered by the ACT
team.

•

Open all incoming mail addressed to the client that arrives at the ACT office.

•

Inter-Agency collaboration with community supports and services.

•

Frequent visits and ongoing contact to support the client with treatment plan goals.
(Northern Health, n.d.)
Discharge planning. A client is discharged upon mutual agreement between the client

and the ACT staff for termination of services. Discharge Criteria is defined by:
a) Client has successfully reached individually established goals for discharge, and/or;
b) Client has successfully demonstrated an ability to function in most major role areas (i.e.,
work, social, self-care) without ongoing assistance from the program, and/or;
c) Client moves outside the geographic area of the ACT programs responsibility, and/or;
d) Client declines or refuses services and requests discharge. (Shoemaker, 2010)
Importantly, client determination is at the heart of evaluation of treatment goals as well.
The staff stated that the yardstick of the success of a treatment plan is the client's self-reporting
that the treatment goal has been met, and that client-centric care also takes cognizance of what
the client feels about medication. In other words, client satisfaction or judgment determines the
status of goals.
Team members ' statements. Let us also know about opinions of the team members

regarding client-centric care, which have been paraphrased as follows:

45
1. Client-centricity of the ACT model aligns with the values of social work. Contrasted with a
prescriptive approach, this model uses a partnership approach and its philosophy consists in
psychosocial-rehabilitation according to which everyone has the right to self-determination.
2. The client-centered approach can be strengthened if the staff assess their own social work
practice and guide themselves to providing client-centric care by enabling or empowering the
clients to have control over their own lives which they often lack.
3. Clients may not meet staffs personal standards of daily tasks nor does the staff impose their
own standards on clients. The minimum standard that is expected of clients upon their
assessment is safety, for example in cooking.
4. In order to provide client centric care, one needs to know as much as one can about the client.
This involves taking the client history, making assessment, and then figuring out what is
most beneficial for the client by involving the client.
5. Client-centric care involves asking the client what he or she wants in a number of areas:
medicine, culture, community, and money. This step is followed by appropriate action by
bringing together and working with the PCC/mini-team and the client.
6. Treatment plans are not developed at the team's desk. The staff takes the CAN-C, followed
by formulation of a treatment plan which is read by the client. In fact, clients review or read
all the plans related to them such as community plans and weekly service plans. For example,
if the client does not like the draft of the weekly service plan, it is modified accordingly.
Also, medications are discussed with clients in terms oftheir satisfaction and feedback.
7. The client-centric approach extends to conveying the information from the client to the team.
In other words, a patient understanding of clients' needs and statements are important, so that
any important information might not be missed.

46
In this regard, I remember a personal case in respect of a close relative whose queries to
an assistant were not conveyed to the physician, which kept the patient in dark.
I have discussed the challenges and dilemmas related to client-centric care in the next
chapter.

Culturally Competent Services
Northern Health (NH) ' s view of Aboriginal Health is captured in the following statement:
Aboriginal health is holistic. It encompasses health determinates, is supported and
fostered by Indigenous knowledge and know-how, and is community-based and driven. It
includes health/mental health and addiction needs that call for accessible programs and
services for all ages and stages of life. (Northern Health, para 2).
Moreover, one of the objectives ofNH' s Aboriginal Health Services Plan 2007-10 was to
improve cultural competency within NH through cultural training for its workforce and through
culturally appropriate service policies.
The NH ACT team has Aboriginal partners such as Prince George Native Friendship
Center (PGNFC), Carrier Sekani Family Services (CKFS), and Center Interior Native Health
(CINH) that are important resources for knowledge about culturally sensitive practices as well
for social engagement of Aboriginal clients. Of them, PGNFC promotes "wellness, balance and
healing. In terms of the medicine wheel, balance means being strong emotionally, physically,
mentally and spiritually" (Prince George Native Friendship Center), whereas with the guidance
of elders, CKFS provides for healing and empowerment of Aboriginal families. Similarly, CINH
follows a holistic approach to healthcare by promoting "physical, spiritual, emotional and
cultural harmony within all Aboriginal Peoples who reside in North Central British Columbia"
(Center Interior Native Health). It may be mentioned that the use of such community resources

47
imparts cultural sensitivity to the NH ACT program. This also addresses the limitations affecting
non-ACT models of treatment, as explained in the literature review section.
The staff informed that the team is fortunate enough to consult with the ACT peer
support worker who has lived in Aboriginal communities for many years and as such, the team
strives toward cultural awareness and competency. The staff also shared that a client not making
eye contact was a clue that it was sometimes a cultural determinant of behaviour. The staff aptly
stated that culture is something not a book that one can read. As such, cultural competence
demands observation and patient understanding of norms and of the ways people of different
cultures act and behave. They gave an example that the team members struggle with knowing
how First Nations clients handle their money. Some of the clients receive money and give it
away to families or friends. So the team gets to understand that it is because First Nations people
believe in sharing- if they can share food and clothes, they can share money as well.
The staff said that factoring cultural considerations into intake and assessment is "factfinding". This is possible by contacting families to learn about cultural norms and values and by
exploring the sources that can be useful. For example, if the client is raised on an Indian reserve,
the ACT team goes there to seek their help in determining how the client can be served better.
Thus, I learned from the experience of social workers that connections are extremely valuable
while you are working in a community. Also, one needs to refrain from assuming that the client's
way of living is the same as that of the practitioner' s. For example, the staff stated that often First
Nations attribute illness to the spirit of a demon and they might prefer traditional healing
methods such as sweat lodges.
Apart from interviewing the team, I gained a deeper understanding of cultural competence
through research (explained in chapter one and two). I understand that real life situations

48
challenge application oftheoretical knowledge, but I believe in expanding the horizon of my
understanding so that I may overcome the constraints faced by practitioners. I agree that simply
knowing about cultural competence is not enough, but knowledge is the first step toward it. At
the same time, I also believe that social workers should steer clear of the risk of generalization.
Just because a society is culturally diverse, culture-based intervention does not automatically
lend itself to efficacy unless practitioners understand their clients well. It is to be borne in mind
that social workers should not proceed with any preconceived notions but should always take the
opinion of the client into account. In other words, if an Aboriginal client is not interested in or is
indifferent to the use of cultural practices, then a mainstream treatment approach is appropriate.
In this regard, staffs viewpoint strikes a chord with my thinking that it is crucial to ascertain or
understand identification of First Nations clients' to their culture rather than assuming that every
Aboriginal client prefers sweat lodge ceremonies. After that, the people or organizations that
could provide support in traditional healing can be located and partnered with.

ACT and Community Work
Interaction with ACT team members as well as personal observation revealed what skills
or aptitudes are needed for a social worker to operate successfully in communities. The skills
include: the ability to form bonds with the community and different agencies such as shelter and
housing; communication skills that convey the ability and willingness to collaborate with
community organizations; and keeping oneself updated on ongoing development in communities
where one serves.
Below are some of the paraphrased statements of staff in this regard:
•

Flexibility is one of the skills required since once team members leave their office and are in
community, they are in a different environment and do not know what situation or

49
circumstances they will find themselves in. Flexibility connotes the ability to provide
services as per the situation, which could be different from the mode or nature of service
which was provided previously. Further, good communication and assessment skills are
critical to community work.
•

Building relationships is required; networking is important.

•

When team members interact with the staffofthe agencies (such as a shelter) in communities
as representatives of the ACT team, it is very important to form a good working relationship
with them. With this, the team can expect to get agencies' help in serving the clients better.

•

Community skills include patience; knowing the community; awareness ofthe resources;
empathy; and being realistic, kind, persistent, assertive, and genuine.
I asked the staff whether they faced challenges working in communities. They responded

that there was largely no challenge or issue involved except for personal safety for which the
team had safety measures in place.
Community Resources. The resources listed below indicate that community resources

are wide in scope in terms of diverse services that takes into consideration needs pertaining to
gender, sexual orientation, and age differences. I think it is equally important that clients benefit
substantially from the available resources. As such, clients' needs, mood, and personal interest
should be ascertained, so that the client may be introduced to the best of the resources.
a) Men' s Shelter: Ketso Yoh Center (24 hour emergency shelter for any male, 19 years and
older), St. Pat's Transition House (addictive recovery), Activators Society/HalfWay
House Forensics, and Active Support Against Poverty (ASAP).
b) Women' s Shelter: Active Support Against Poverty, Phoenix Transition Housesupportive recovery beds, Elizabeth Fry Society, and Quebec St. Women' s Shelter.

50
c) Youth Shelter: Reconnect, and Melville House.
d) Food/Clothing: St. Vincent De Paul, Soup Bus; Soup Line; Good Food Box Program.
e) Northern Health Authority Residential Adult Housing: Iris House, Davis Drive, Urquhart
House, and Hazelton Street Residence.

f) Youth Housing: NH has no current youth housing. All housing access for youth is via the
Ministry of Children and Families.
g) Community Resources for Youth include Intersect Youth & Family Services, Teen
Mothers Resource Program, Sexual Abuse Intervention, and New Hope Society (support
and assistance for street involved women)
h) Community Resources for adults include AIMHI (support for persons with disabilities),
Sexual Assault Center, Ace Center for Empowerment, and BC Schizophrenia Society,
Education and Support Services, Seniors Outreach Program, Gay and Lesbian
Association, Native Friendship Center, and CMHA (Canadian Mental Health
Association) Connections Clubhouse.
i) Emergency Crisis Intervention resources include Community Response Unit (CRU).

j) NHA Community Follow Up resources include Community Acute Stabilization Team
(CAST), Eating Disorder Team, and Community Outreach and Assertive Services Team
(COAST).

Visit to Northcoast Behavioral Healthcare System (NBHS), Ohio
Located in Northfield in Cuyahoga County, Ohio, NBHS provides ACT treatment that
falls under the Community Support Network (CSN). CSN delivers a full range of consumeroriented mental health outpatient services. NBHS is one of the six psychiatric hospitals operated

51
by the Ohio Department of Mental Health (ODMH), and has the mission to make "recovery
reality", with the vision of "partnering to achieve wellness."
My first day at NBHS began with the Learning Associate Center Orientation, one of
whose elements was cultural competency with the following five components:
•

Understanding one's own cultural background.

•

Acknowledging the client's different culture, value systems, beliefs and behaviours.

•

Recognizing that cultural difference is not synonymous with cultural inferiority.

•

Learning about the client's culture.

•

Adapting optimal health delivery to an acceptable cultural framework (The Learning
Associate Center Orientation, p.17).
After orientation, I was given self-defence training that is provided to new hires/students

so they may know how to defend themselves in cases of emergency. I also visited residential
services of the CSN and met with ACT clients, as well as the Alcohol, Drug Addiction, and
Mental Health Services (ADAMHS) Board of Cuyahoga County, which is responsible and
accountable for planning, funding and monitoring of addiction and mental health services. I
interacted with ADAMHS 's review specialist to know about the funding process for ACT
programs since some programs had been closed because of the lack of funds.
I learned that the NBHS ACT team is an interdisciplinary team that is "designed to
provide aggressive outreach, maximizing community living and reducing episodes and duration
of inpatient stays. Services include Community Psychiatric Supportive Treatment (CPST),
Pharmacological Management, Counseling and Support Services" (NHBS Brochure, n.d.).
Consisting of 6 case managers, 2 nurses, and 1 psychiatrist, the team is entrusted with
transitioning the patients out ofhospital, where they have lived most of their life, to community.

52
It is currently serving 86 clients, of whom 50 percent are African Americans, 45 percent

Caucasian Americans, with the rest 5 percent falling in the "others" category.
The NBHS ACT staff introduced me to an interesting tool called Solutions for Ohio's
Quality Improvement and Compliance (SOQIC) which is a standardized format used for mental
health assessment, individual service plans, annual health histories, annual health assessments,
and progress notes of case managers, nurses and doctors. In other words, all assessments
including filling of forms are based on SOQIC that provides an "integrated documentation
system" for mental health and addiction treatment and simplifies paperwork.
In regards to client-centric assessments, the staff informed me that the initial mental
health assessment takes into account the comprehensive history of the client in terms of such
components as living situation, family, origin, religion, culture, ethnic history, developmental
issues history, sexual history, learning difficulty, medication history, legal history, and substance
use. The client's family is also contacted to gather information for assessment. The clinician then
summarizes the information. Afterwards, the Diagnostic and Statistical Manual ofMental
Disorders (DSM-IV) is used for diagnosis, followed by the team's recommendation for
treatment. This is for the initial service plan. The second assessment for the client is done for
psychiatric evaluation, which includes questions related to the cultural aspect. This apart, there is
a nursing assessment. All these assessments are followed by the formulation of a client-centric,
Individualized Service Plan (ISP) within 30 days ofthe client's introduction to the ACT team,
and is reviewed with the client every 90 days. I reviewed the format of ISP that was helpful in
knowing what makes up such plan or what its components are. For example, it contains: the goal
and the objective stated in collaboration with the client; desired results (in client's words); client

53
strengths and how they will be used to meet this goal; skills/knowledge needed; and
natural/community supports needed.
Besides, weekly clinical supervision meetings take place on Wednesdays at which team
members hold in-depth discussions on client cases. I learned that there was no overlapping of
functions of the team members.
In respect of cultural competence, I learned that CSN captures the ethnicity of the client.
This apart, the NBHS ACT team is in the process of incorporating a form, which uses race,
ethnicity, gender and age, in the intake process. Interestingly, 45 out of the 86 clients do not
know how to speak English fluently. Therefore, language interpreters assist with communication
with clients.
Besides, the hospital has a Cultural Awareness Committee that meets once a month, takes
ethnicity data, and comes up with survey summaries to provide culturally competent treatment.
Moreover, hires are provided training in cultural competence within 30 days of hire in order to
provide effective patient care. It is known as "Cultural Competence 101 " taught by Professional
Development Program Specialist from the Diversity Center ofNortheast Ohio. As per the
course' s learning objectives, the participants will be able to:
•

Review participant sensitivity and awareness about various aspects of diversity and
culture and how differences impact communication.

•

Discuss effectiveness of employees in communicating cross-culturally.

•

Recognize awareness of unconscious bias and how it effects relations with clients and
colleagues.

•

Identify skills to help create a more inclusive workplace environment.

54
What is striking is that when asked about the challenge involving client-centric services,
the staff pointed to the similar challenge as faced by the ACT team in Prince George: clients
sometimes ask for something that is not healthy for themselves. Further, when the clients are at
risk of harming themselves or others, they are given a pink slip by the psychiatrist because of
which they are checked out at the hospital against their will.
Overall, my visit to NBHS enlightened me on ACT considerably.
In the next chapter, I will discuss the issues and challenges associated with ACT as well
as my personal reflections.

55

Chapter 4

Issues and Challenges
The practicum enabled me to understand the external and internal issues and challenges
ACT team members can encounter, which are described below:
1.

Divergent Ideologies ofTeam Members: Since an ACT team is multidisciplinary, its

members with different training backgrounds tend to hold different viewpoints or ideologies in
respect of client care. According to the staff, the social work code of ethics states that the client
is the social worker's foremost concern, while other professional bodies do not subscribe to this
viewpoint. This can lead to conflict among team members as to how clients should be treated.
Some members think that rules and schedules are needed and clients are expected to abide by
them, for example in terms of arriving at the NH office at a particular time. On the other hand,
members with a different background feel that the team could be more flexible in serving clients
with severe mental illnesses who sometimes could not figure out what time it was or how to get
an appointment. Further, those with a social work degree tend to focus a lot on the cultural aspect
ofhealthcare and on structuralism, in contrast to members from other disciplines whose focus is
quite different (Personal communication, July 30, 2013).
Thus, the staff suggested holding more workshops that will enable the team members to
orient their mindsets to client perceptions ofhealthcare.
2.

"Fine line" between Client Needs and Service Providers' Perceptions about Their Needs:

I learned how social workers come across situations when clients desire or demand things that
are not in clients' "best interest". For example, while clients have a right to their money, addicts
among them might spend it on buying drugs and alcohol. Similarly, a client who is depressed and
suicidal might ask for something that will cause him or her harm. In such cases, social workers

56
have a reason not to give in to clients' needs. Thus, the staff stated that there is a fine line
between the perceptions of the client and the team as to what is best for the client.
Further, the staff shared that there could be an issue of paternalism when a team member
sought an excuse not to give the client his or her own money if it could be used to buy drugs, and
thereby, seeking to prevent the client from harm. The staff added that practitioners should refrain
from enabling clients to make bad decisions in the name of client-centered practice by drawing
boundary lines. For example, the staff that accompanies a client for grocery shopping with an
allotted grocery budget, refuses to buy him Gravol since the client has a history of abusing it.
Interestingly, the staff summed up this story with a powerful statement that though clients may
get mad when faced with such situations, honesty and professionalism eventually contribute to a
better client-social worker relationship.
Similarly, the staff pointed out a "huge" issue related to Form 20, which is a community
committal form, which requires certain tasks for the client such as taking medications, living in
appropriate accommodation, staying away from drugs and alcohol. As mental health workers, the
team members are required to ensure compliance with Form 20, but clients might not like that,
which affects workers' relationship with clients.
Such cases involving dilemmas around client empowerment reminded me of the models
of resolution of ethical dilemmas that I learned during my MSW course. For example, Miller
(2007) presents the Ethical Principles Screen (EPS) framework developed by Dolgoff,
Loewenberg, and Harrington, which prioritizes protection of life as the primary ethical principle,
enabling practitioners to make decisions when conflicts arise between principles embedded in a
professional code of ethics.

57
3.

Staffing, Workload, and Overlapping: I learned that a lot of clients need help with

activities of daily living such as shopping and laundry, which requires more staff. Further,
because of workload resulting from overlapping of functions, staff desire more distinct roles. For
example, the staff indicated the need for a better delineation of individual roles as well as hiring
more workers to offset workload.
In this regard, I think quick recruitment to an ACT team is also quite important for
effective client care. For example, the psychiatrist's position fell vacant during my practicum.
On positive note, however, the staff stated that overlapping was usually not a problem
and that there were sometimes situations when they had to discuss resolving issues arising from
the use of different approaches to client care.
An interesting and thought provoking explanation was put forth by the staff that

attributed overlapping to generosity of members, which issued from the integrated nature of ACT
services, and which is what makes ACT unique. As a result, sometimes a social worker dispenses
medication, which is typically the role of nurses, though specifically their roles are quite distinct.
4.

Culturally Competent Services: The staff stated that culturally competent care could

definitely be improved and there is a need for a better understanding of diversity of culture in the
community the ACT program serves. Also, the staff stated that the First Nations clients needed
more than medication and that strengthening culturally competent care demanded more time
since the team members are faced with a "fast paced" job.
Additionally, the staff was quite forthright in suggesting that the cultural aspect of care
begins with the environment at the workplace and said that Aboriginal culture should be
reflected in the office environment, while pointing to the lack of a poster related to this culture.

58
The staffbelieved this was a step toward bridging the cultural gap between service providers and
the clients.
5.

Clients with Long Histories: In conversation with the staff, the staff indicated that the

biggest challenge was helping the clients, who had long histories with poor outcomes and
failures, to overcome their belief that they could not succeed.
In other words, social workers need to be prepared for assisting a diversity of clients
whose cases may vary, to the extent of clients' having fixed mindsets about recovery or their
lack of faith in recovery owing to previous failures in life.
It is pertinent to mention what staff suggested for improvements in the interest of clients.

One of the areas where clients can be served better is that of corrections and forensics, apart from
cultural competence and a clearer delineation of roles. Besides, the staff suggested that there be a
provision of seeking client feedback on satisfaction with services and program.
Personal Reflections

At the outset, the integrative nature of ACT-because of which effective treatment does
not hinge on a predominant role of any particular discipline-- makes me visualize the position of
a social worker as part of an orchestra. Any preparation for assuming the role of social worker on
such a multidisciplinary team requires not just training or an orientation session but a mindset
that is receptive to both client-centric care and teamwork. In other words, just being a good
social worker in terms of aptitude and skills is not enough, but an understanding and appreciation
of the roles of other team members and a willingness to accommodate their concerns and
compulsions, arising from differences in backgrounds, are equally necessary. In this regard, I
admire the professionalism and maturity of the Prince George ACT staff who, in response to my
interview questions, exhibited an understanding of the ideological differences stemming from the

59
differences in their individual training, rather than any attributing issues or concerns to personal
differences. In fact, the staff stated that they work as a team, and therefore, when one member is
away, the other member picks up the required task.
I also realize that performance of the social worker's role while being on a
multidisciplinary team is challenging. It is not enough to know one's code of conduct or
professional duties. While on a team, team skills are also required especially when the team
members differ with you in terms of dealing with a client. Thus, the ability to work on a team is I
think an additional requirement that goes beyond one's typical role as a social worker. Besides,
composure and tact are also needed since as a professional one might know one's job well, but
the external constraints in terms of inadequate staff or workload could be disappointing,
especially when you are highly motivated and you feel constrained by the external forces to
deliver the best to the client. Thus, one does not operate in a vacuum. And one needs enough
patience and maturity to be able to work in different circumstances that are beyond personal
control, and at the same time, one should be ready to advocate change or reform when an
opportunity arises. In this regard, I appreciate the straightforwardness of the ACT social workers
who aired their views when I interviewed them.
I found that staff were keen to deliver the best in terms of client-centric and community
care. However, a client- centered approach is beset with challenges, stemming from the lack of
adequate staff and time. For example, though ACT involves work in communities, on some
occasions clients have been asked to come to the ACT office for injections. Besides, clients who
are assisted with grocery shopping once every two weeks might need more frequent shopping for
such perishable items as milk and yogurt. But I feel that such challenges can be handled by
addressing the constraints and that team members appear quite willing for improvements. In this

60
regard, it must be mentioned that the capacity for improvement should not be seen in negative
terms, since efforts at consistent improvements reflect commitment.
Besides, I noticed that most of our clients were male, and we do not have male staff except
for a couple of casual frontline male workers. Gender of the practitioner can be an important
determinant for a client to be more open in interactions. For example, male clients might prefer
discussing a problem with male practitioners. I give an instance related to the practicum. The
other day, I went to deliver medications to the clients along with the front line worker who was
surprised to find that a male client interacted with me so well and easily got along with me. The
colleague opined that the client might be feeling comfortable since I am a male.
Overall, the practicum enriched my understanding of a client-centred approach- a
practitioner needs to exercise prudence when faced with ethical dilemmas by knowing when and
how to draw a line between client-centeredness and client interest. The staff clarified how new
workers in the mental health field could misconstrue being client-centered as denoting listening
to and validating clients' delusional thoughts. Thus, I learned how and when social workers can
"gently challenge" such thoughts by redirecting the client to a different topic. Further, what I
find striking is that the limitations ofhealthcare systems which are devoid of cultural
competence, as discussed in the literature review section (especially p. 22), are substantially
addressed by the NH ACT program which is marked by client-centricity and cultural sensitivity.
For example, the elaborate recovery planning process is constituted of steps such as
comprehensive assessment, client strengths, sharing and revision of the plan with the client, and
assessment of the client' s overall satisfaction with his or her goals every six months. Further, as
mentioned in the literature review section, Aboriginals have been found avoiding mainstream
treatment because of such issues as racism. In contrast, the community outreach program and

61
psycho-social rehabilitative ACT (person-centered approach) serve to assuage any such concerns
of Aboriginal clients.
I now briefly share my thoughts on a comparison between the NH ACT program and the
Ohio-based NBHS ACT program. While the NH program is excellent in terms of outreach and
teamwork, I liked that NBHS has a cultural awareness committee that lays emphasis on cultural
competence of service providers. I think that NH should have such committee that can discuss
issues related to cultural competence of team members, listen to their viewpoints, understand
their challenges and compulsions, if any, and offer recommendations for the necessary
improvements on this front.
An important takeaway for me is the statement by the staff in regards to client-centric

treatment, according to which it is important for a clinician to understand the best practices and
incorporate them into the treatment, but this should be inclusive of clients' right to selfdetermination and their willingness to accept those treatment approaches. Indeed, this viewpoint
and the other statements by the staff, as stated earlier, echo anti-oppressive social work practice
that I read about in my pre-practicum classes.
This practicum introduced me to the challenges that I was unaware of. As I step out in the
field of ACT, I feel myself confident since I am aware of operational aspects of ACT, even
though I understand it is a challenging task and the level of work that I did during practicum was
at the level of learning as an MSW student, not as an actual ACT professional.

62
Chapter 5
Conclusion

My practicum at Northern Health was a great enlightening experience in terms of gaining
skills such as conducting mental health assessments, acquiring knowledge of ACT and related
aspects, and becoming aware of the operational side of ACT. What I find extremely helpful is the
interaction and working with team members who come from different disciplines and gave
insightful responses.
What I learned about client-centric services will be beneficial for my future practice with
communities. Though my previous experience in the social services field made me aware of the
dilemmas and challenges to which I responded using my judgment, this practicum was more
comprehensive as I not only gained knowledge of procedural aspects but learned how team
members responded to dilemmas around clients' right to self-determination. My familiarity with
the issues and challenges, as described in the preceding chapter, will indeed help me prepare for
delivering ACT services as a social worker. I am eager to sharpen the skills I acquired, especially
on the assessment and crisis intervention front.
I discerned a linkage between ACT and anti-oppressive social work practice, which I had
read about in MSW courses, in terms of emphasis on client empowerment. In practice though,
there could be challenges to client empowerment, such as a clash between client need and
workers' perception of client interest. However, the practitioner should be able to use good
judgment in resolving such cases. And I personally feel that in some situations, models of ethical
dilemmas can be helpful. In this regard, I am glad that the MSW program introduced me to a
number of perspectives, topics, and theoretical frameworks. Above all, it also provided
opportunities for gaining practical experience.

63
I understand that in a different regional setting, I may encounter a different experience if I
work as an ACT professional. However, this practicum carries great value for me in laying a
strong foundation.

64
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Appendix
Appendix A: Interview questions for ACT social workers

ACT and Clinical Social Work Practice in a Particular Context ofNorthem Health
1. Please explain your role and function, and the range of services offered to the clients.
2. What are the parameters you use in conducting assessments and what issues or challenges do
you face in conducting assessments?
3. How do you engage family members of clients and/or provide family support in conducting
assessments for Northern Health clients in particular and in general? Do you encounter any
difficulties in this process? If yes, what are they?
4. Is there any overlapping with the functions of other ACT team members? If yes, does it
create any problems in fulfilling your roles?
5. How do you coordinate your activities with the ACT team?
6. According to BC Standards: "All ACT team members shall assess and document the client's
mental illness symptoms and behaviour in response to medication and shall monitor for
medication side effects." Please describe how you assess and document that.
7. What are the crisis-intervention skills employed to deal with potential crisis situations such
as suicide (just as an example)?
ACT and Cultural Competence
8. How are cultural considerations factored into intake, assessment, treatment, and discharge?
How do you deliver culturally competent services?
Client-centred Treatment/Services/Support
9. Since ACT involves client-centered treatment services and support, how do you ensure this
in fulfilling your roles? What are your practices in this regard? For example, according to BC

75
Standards, the client and the team "work together to formulate and prioritize the issues, set
goals, research approaches and interventions, and establish the [treatment] plan." Is this your
approach or that of the ACT team to make the treatment client-centered?
10. Do you face any issues in providing client-centered treatment/services?
ACT and Community Settings
11. What are the skills required to serve in communities?
12. Do you encounter any difficulties or face any issues in working in communities?
Overall Inputs
13. What are your general observations and experiences in regard to ACT, especially in the
context of serving Northern Health clients?

Appendix B: Questions for other ACT team members
ACT and Clinical Social Work Practice in a Particular Context ofNorthem Health
1. Please explain your role and function, and the range of services offered to the clients.
2. According to BC Standards: "All ACT team members shall assess and document the client's
mental illness symptoms and behaviour in response to medication and shall monitor for
medication side effects". Please describe how you assess and document that.
3. What are the crisis-intervention skills employed to deal with potential crisis situations such
as suicide Gust as an example)?
ACT and Cultural Competence
4. How are cultural considerations factored into the treatment/services you provide? How do
you deliver culturally competent services?
Client-centred Treatment/Services/Support

76
5. Since ACT involves client-centered treatment services and support, how do you ensure this
in fulfilling your roles? What are your practices in this regard? For example, according to BC
Standards, the client and the team "work together to formulate and prioritize the issues, set
goals, research approaches and interventions, and establish the [treatment] plan." Is this your
approach or that of the ACT team to make the treatment client-centered?
6. Do you face any issues in providing client-centered treatment/services?
ACT and Community Settings
7. What are the skills required to serve in communities?
8. Do you encounter any difficulties or face any issues in working in communities?
Overall Inputs
9. What are your general observations and experiences in regard to ACT, especially in the
context of serving Northern Health clients?

Appendix C: Summary of steps to make and carry out recovery plans

1. Comprehensive assessments, including ALL past records.

2. Fill out face sheet (page 1)

l
3. Fill out draft of client strengths on top of page 2

4. Present Comprehensive Assessment at Clinical Team Meeting

5. Mini Team and Client have Recovery Planning Meeting

77

l

FOCUS AREAS: use client' s overall goals/needs and the clients responses to several

questions (on the template) to describe priority focus areas

l

GOALS: transform overall goals/needs into specific 6-12 month goals
PLANS: list actions to attain each specific goal:
>>>>>>>> 1st draft recovery plan

6. Full team Recovery Planning Meeting: all ACT staff provide input. Client is invited to this
meeting, if they wish to come
>>>>>>>> 2nd draft recovery plan

7. Client and care coordinator discuss 2nd draft. Client provides input and changes are made
accordingly
>>>>>>>> final version of recovery plan
8. Client & care coordinator make a client weekly schedule which includes all ofthe staff and
client actions and activities that are listed in the recovery plan

9. Client weekly schedule is used to make the daily staff assignment sheet for every day of the
week (with specific staff assigned to every action/activity).

10. At the daily am ACT team meetings, the shift manager for that day makes sure that the
specific assigned staff (or another staff) remembers to carry out the actions.

11. Client and ACT staff carry out the plans and activities as specified in the recovery plan

78
12. Ongoing assessment of goal attainment

13. At 6-12 months: assess overall goal attainment and reassess as needed
>>>>>>>> repeat steps 1-12