Hands On

When the sickest of Harris County's mentally ill break down, an ACT team is there to pick up the pieces and put them back together again

Harris County's ACT program started in March 1996 with 40 patients, who were assigned to a ten-member treatment team consisting of a psychiatrist, a nurse, an employment specialist, rehab counselors and social workers. There are now three ACT teams in Harris County and, at last count, 295 patients, who are referred to as clients. By design, ACT anticipates that all of them will need the program indefinitely, if not for the rest of their lives.

"These are the sickest people in the system," says Mitchell, who became the director of Harris County's program in 1999. "The goal is to get them an apartment, maybe a job, or somehow situated in as normal a life as possible. Some get there, after years. Some never get there."

A handful of Mitchell's clients have jobs. Most of them are poor and rely on some form of public assistance. One in four have been in jail, some repeatedly, for crimes attributable to their illness. About a half-dozen were court-ordered into the program, either as probationers or, in the case of those found mentally incompetent or not guilty by reason of insanity, upon release from a state hospital.

While most of their work is on the streets, ACT members meet daily for client reviews.
Monica Fuentes
While most of their work is on the streets, ACT members meet daily for client reviews.
ACT's Karen Dorrier: Flexibility is needed to cope with the unpredictable.
Monica Fuentes
ACT's Karen Dorrier: Flexibility is needed to cope with the unpredictable.

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In the 28 years since it was founded in Madison, Wisconsin, ACT has been the subject of no fewer than 25 controlled studies comparing the program to clinic-based services. A soon-to-be-published review of that research found that ACT never failed to reduce hospital admission rates -- by as much as 78 percent in some groups -- and cut the overall cost of treating serious mental illness.

Yet as recently as 1990, only seven states reported using ACT. In 1996 the National Alliance for the Mentally Ill, an influential advocacy group, began promoting ACT, with the goal of establishing the program in all 50 states by 2002. Some 36 states have adopted ACT, though most of them have embraced it rather halfheartedly; only about a dozen have treatment teams in more than half their community mental health centers.

ACT's basic blueprint, which Texas adheres to as a matter of policy, calls for one ten-person team for every 100 of the most chronic cases. However, that equation can be manipulated to take in a wider range of mental patients. Those whose symptoms make employment impossible, for example, can be assigned to a more intensive ACT team that emphasizes "illness management." Those who are more independent -- who may have a job, live on their own or with a supportive family -- can be "stepped down" to a team that doesn't offer such ever-present support.

The latest use for ACT, and one of the most promising, is helping mentally ill people stay out of jail. Since 1998 four ACT teams have been working out of the Cook County Jail in Chicago. The results of a two-year study of 13 cases, soon to be published by Loyola University, are impressive: total arrests -- down from 116 before ACT to 13; days incarcerated -- down from 1,546 to 213; and inpatient days -- reduced from a total of 990 to 175 after two years.

The researchers calculated that the net savings to Cook County taxpayers for those 13 cases was $455,800.


There is some confusion inside The Caring Place Adult Daycare and Beauty Salon when Mitchell learns that Darnell isn't here. On his cell phone, he dials ACT headquarters at Northwest Community Service Center, on Dacoma Street. A moment later a caseworker tells Mitchell that Darnell is only five minutes away, at a therapeutic day program off the North Freeway. He's sitting in the lobby when Mitchell arrives.

Darnell, now 49, is a big man, well over six feet tall and at least 250 pounds, with a full head of hair that's graying softly around the ears. He has a Fu Manchu moustache and long sideburns. He's wearing jeans, tennis shoes and a black warm-up jacket and sweatshirt. Darnell greets Mitchell shyly, but he's obviously glad to see him.

Mitchell rarely crossed paths with Darnell during his six years with the Tri-County agency. But by the time Harris County's ACT program opened for business, Mitchell says, Darnell had become "a legend" in local mental health circles. Mitchell made him a charter client of the program.

"When Darnell wanted something, he wouldn't give in. He would just pester people and go on and on," he says. "Then he'd get angry....Darnell is the only guy I know who could talk the police into buying him cigarettes. He used HPD like a taxi service to the hospital."

All the time, apparently. By the mid-1990s Darnell was spending as many as 300 days a year in the hospital. "The community" didn't represent freedom and normalcy to Darnell, only loneliness and terror. Too much community, or any at all, can be overwhelming for people with mental illness. A few of Harris County's ACT clients are so emotionally fragile they can't visit the program's offices without risking a psychotic episode.

Moreover, there are no longer any Fairweather Lodges and far fewer halfway houses like Terry Hall in Harris County. The housing void was filled by a network of personal-care homes and unlicensed boarding houses. Too few to meet demand, such establishments frequently exercise their right to be arbitrary. People with mental illness lose their room and board when they're hospitalized. Or their symptoms, including alcoholism and drug abuse in half the cases, make them undesirable tenants.

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