Assertive Community Treatment.

While at PPOH, I spent two days a week work­ing with an Assertive Com­mu­nity Treat­ment (ACT) team.

ACT is some­what like a psy­chi­atric hos­pi­tal out­side of a hos­pi­tal. It is an evidence-based prac­tice1 that fea­tures a mul­ti­dis­ci­pli­nary team (social work­ers, psy­chol­o­gists, psy­chi­a­trists, nurses, case work­ers) that works with a small group of patients who often expe­ri­ence impair­ing psy­chi­atric symp­toms. It pro­vides com­pre­hen­sive and flex­i­ble psy­chi­atric ser­vices. All of the care occurs in the community.

The ACT team I worked on was staffed with:

  • one pro­gram direc­tor (social worker)
  • one team leader (social worker)
  • one MICA (“men­tal ill­ness and chem­i­cal addic­tion”) spe­cial­ist (social worker)
  • one voca­tional spe­cial­ist (social worker)
  • one enti­tle­ments spe­cial­ist (almost-graduate from social work school)
  • two case work­ers (one who had recently earned a social work degree)
  • one reg­is­tered nurse
  • one sec­re­tary (who did much more than cler­i­cal work)
  • two psy­chi­a­trists (our com­bined hours did not fill a full-time position)

Dur­ing my time there, I pro­vided care for about 35 patients. (The other psy­chi­a­trist pro­vided care for the other 35 patients.) The staff to patient ratio is pur­posely kept low, as ACT is con­sid­ered an inten­sive intervention.

Patients who are referred for ACT ser­vices must have been psy­chi­atri­cally hos­pi­tal­ized (often invol­un­tar­ily) at least four times in the past year. They often have mul­ti­ple emer­gency room or mobile cri­sis vis­its. Other out­pa­tient ser­vices have often failed or have been insuf­fi­cient to pre­vent crises and hospitalizations.

Thus, a chief goal of ACT is to keep peo­ple out of the hospital.

The ACT model dic­tates that the team (as a whole) must make a total of at least six con­tacts with each client2 every month, prefer­ably in the com­mu­nity. One of these vis­its should be a meet­ing with the psy­chi­a­trist. Some patients reg­u­larly came to the office for their vis­its. Oth­ers, how­ever, could not or would not come in. We thus went out to them. (Hence the adjec­tive “assertive”, which, in some cases, could be con­strued as “coer­cive”. More about coer­cion later.)

If I did not see patients in the office, I often saw them in their apart­ments. (Lim­its and bound­aries do not blur, but they cer­tainly shift. My expe­ri­ences in these res­i­den­tial set­tings inspired this post. To be clear, there were a few indi­vid­u­als who I never met alone. I insisted they meet me out­side or in the clinic. Some of this was due to their past behav­iors; some of this was my gut instinct.) For those who did not feel com­fort­able meet­ing in their apart­ments, we met in lob­bies, parks, or chat­ted dur­ing walks. (Dur­ing my time on ACT, I came to value talk­ing and walk­ing as a ther­a­peu­tic intervention.)

ACT was for­merly deemed “long term care”; some patients have been on ACT teams for over a decade. (This is often due to repeated psy­chi­atric hos­pi­tal­iza­tions despite ACT ser­vices.) Most of the patients had psy­chotic dis­or­ders (such as schiz­o­phre­nia) and, sur­pris­ingly, many of them had actively involved fam­ily mem­bers. I sus­pect that this impacted who was referred to ACT; fam­ily mem­bers were often the ones bring­ing peo­ple to the hos­pi­tal for care (ver­sus call­ing the police, etc.) Most patients “grad­u­ate” from ACT within a few years: They stay out of the hos­pi­tal, become more involved in the com­mu­nity, and no longer need that level of care.

I learned in this posi­tion that peo­ple with chronic psy­chotic dis­or­ders can get bet­ter. Their symp­toms decrease. They learn how to tem­per their behav­ior so that they do not attract undue atten­tion while out in the com­mu­nity. They set and reach per­sonal goals, like earn­ing high school and col­lege degrees, secur­ing employ­ment, get­ting sober from alco­hol and drugs, and tak­ing care of their phys­i­cal health. They stop smok­ing! Some­times they need a lot of sup­port and a num­ber of years need to pass before things set­tle down, but peo­ple with diag­noses of schiz­o­phre­nia are not doomed to a life of poverty and “low func­tion”.3

I also learned the impor­tance of see­ing patients in their envi­ron­ments. So much of con­tem­po­rary med­i­cine now occurs out­side of a person’s liv­ing sit­u­a­tion. That is often appro­pri­ate and fair (e.g. patients shouldn’t undergo surgery in their own homes). Because of the inti­mate nature of med­i­cine, meet­ing in a “third” loca­tion can help pre­serve pri­vacy and secu­rity. How­ever, we can learn so much about how peo­ple func­tion (or do not func­tion) when we see their liv­ing spaces. We also real­ize strengths that we would oth­er­wise over­look. A neat home, a sack full of old pre­scrip­tion pills, vinyl records of clas­si­cal music, papers all over the floor, pho­tographs of friends and fam­ily, roaches climb­ing over dozens of empty cans of soda: All of that is infor­ma­tion that doc­tors often never have.

It is amaz­ing how peo­ple live their lives. It is remark­able how much peo­ple will tol­er­ate. And it is hum­bling that peo­ple are will­ing to share their lives with you.

  1. From the New York State Office of Men­tal Health: “When com­par­ing recip­i­ents before and after receiv­ing ACT ser­vices, stud­ies have shown ACT recip­i­ents expe­ri­ence greater reduc­tions in psy­chi­atric hos­pi­tal­iza­tion rates, emer­gency room vis­its and higher lev­els of hous­ing sta­bil­ity after receiv­ing ACT ser­vices. Research has also shown that ACT is more sat­is­fac­tory to recip­i­ents and their fam­i­lies and is no more expen­sive than other types of community-based care.”
  2. There is a move­ment in men­tal health—and in other parts of medicine—to move away from the term “patient”. In this par­tic­u­lar ACT set­ting, patients were called “clients”. Some­times they are called “con­sumers”.
  3. The pub­lic rarely hears about pos­i­tive out­comes for peo­ple with schiz­o­phre­nia. There is research that sug­gests that a sig­nif­i­cant num­ber of peo­ple with diag­noses of schiz­o­phre­nia either expe­ri­ence improve­ment or recov­ery of their con­di­tion. Anec­do­tally, I agree.