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 practice[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.”] 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 client[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”.] 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. 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.]
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.
Maria Yang, MD 