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"Part of it is them testing us," Mitchell says. "People come and go in their lives for years, and they want to see if we'll stick it out. But we don't take no for an answer."
Harris County's ACT team members are licensed and experienced, with no shortage of employment opportunities, including private practice. To be sure, they could find work elsewhere in the public system -- at a state hospital, for example, or at a community clinic where the patients come to them. But ACT team members seem uniformly repelled by the idea of sitting behind a desk eight hours a day, doling out 15 minutes of chat therapy to an endless stream of patients.
Indeed, ACT is the antithesis of the community-clinic system. Eighty percent of a team's interaction with a client takes place on the client's turf. This can represent an interesting challenge. Although more mentally ill people are living in the community than ever before, they are almost invisible just the same. Socially isolated by nature, they typically live in poor, crime-ridden neighborhoods where room and board are cheapest.
Team members soon learn that they have little to fear from their clients. However, that's not always true of the people with whom their clients associate. The extent to which the job is dangerous depends on how team members handle themselves, says Mitchell, who has been "belted" once in six years. "If you go in and your emotions are all out in the open, that tends to set things off," he says. "We need people who can at least appear to be calm."
ACT clients with substance abuse problems often end up living with other addicts in close proximity to shooting galleries and crack houses. Addiction is highly prevalent in people with mental illness -- "self-medication" is the term -- and rehab counselors are integral members of the treatment teams.
Bill Munday, a small, energetic Irishman, fills that role in Harris County. Munday spends most mornings driving to the far reaches of Harris County and back to pick up ACT clients for the afternoon group sessions -- which, in Munday's hands, isn't how one might imagine therapy to be. Lately he's been teaching ACT clients how to play chess. A musician, he'll lead the group in a sing-along with his guitar. A couple of weeks ago he tapped the petty cash drawer and took them to the zoo.
"Many of these people here are so desperate, their reality is so ugly and depressing, that it makes sense to step out of it any way they can," Munday says. "We just try to replace it with something else. If we had the budget and the resources, we could do some things that would make your eyes light up."
Being an ACT team member is certainly not for everyone. Recently, a caseworker prospect lasted less than two days, shocked into quitting a job that often looks impossible. "To be good at ACT, you can't be a real rigid person," says Karen Dorrier, an ACT team case manager. "Because you can never predict what's going to happen."
Every morning, Harris County's three ACT teams meet separately to review the status of each client. There is little structure to these gatherings; team leaders simply call a name, and whichever team member saw the client most recently offers a brief assessment. Last month Nancy Gold began one meeting of her team by asking about Elizabeth.
"I saw her yesterday," a caseworker replied. "We need to pick up a new prescription at the pharmacy."
"She has to go to HPD. She says she was assaulted by a man who stole her car."
"He's talking about Indian tribes and migrations. I'm afraid he might be off his medications."
"I was with her yesterday. She's been sober two and a half years, but she still has cravings."
Donald Thomasson, the program's director of clinical care, points out that Jennifer is on probation. "She goes back in [jail] if she starts using again," he says. "I'll increase her Zyprexa and put her on an antidepressant."
It's difficult to say if ACT attracts better clinicians or just a different breed of them. Team members have a luxury that is largely denied community-clinic workers, who see so many patients and have so few resources that their jobs have become an exercise in Medicaid-billing techniques, the most effective of which is moving patients along as quickly as possible. ACT team members have far lower rates of burnout than clinic workers.
The difference is time. Clinics never have enough; for ACT teams, it's sometimes all there is. Team members are only as good as the relationships they form with their clients; everything else is a crapshoot. ACT teams have no authority, legal or otherwise, to compel a client to do anything. If he refuses to take his medication or attend therapy, the ACT team gets "assertive" and spends more face-to-face time with him, wherever he may go. If she breaks down but won't go to the hospital, the ACT team gets a commitment order. If a client is using drugs, the ACT team tries to steer him to treatment, hoping he doesn't get arrested first. If he's put in jail, the team is there when he gets out.