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Treatment Teams Don't Ignore Colleagues' Emotional Needs

Staff on an Assertive Community Treatment team in Baltimore support one another in the face of patients' traumatic circumstances, which may include histories of abuse and ongoing risk of assault.

For clinicians who provide psychiatric services for patients with serious mental illness as part of an Assertive Community Treatment (ACT) team, it can be difficult to deal with the trauma that sometimes comes with the job. Psychiatrists and mental health professionals may experience "vicarious traumatization" stemming from patients' hardships and emotional difficulty when they lose patients to murder or suicide.

Providing ACT team staff with the opportunity to talk about the trauma they encounter on the job is extremely helpful, according to two psychiatrists who work on an ACT team associated with the University of Maryland Department of Psychiatry in Baltimore.

"I think the ACT model is an excellent one for helping staff to deal with the ongoing impact of trauma," said Ann Hackman, M.D. She spoke about some of the strategies ACT members use to help patients with serious mental illness at APA's 2006 Institute on Psychiatric Services in October in New York City.

Also speaking at the sessions was Curtis Adams, M.D. Hackman and Adams are assistant professors of psychiatry at the University of Maryland.

The ACT team currently serves more than 120 adults, most of whom have psychotic disorders and co-occurring substance use disorders, and 30 children.

The team formed in 1990 as part of a research demonstration project and was found to be effective at reducing hospitalization, decreasing rates of homelessness, and improving ratings on quality-of-life measures.

The vast majority of people who receive services from team members have histories of homelessness, and members of the team are often successful at placing patients in housing. There is also a drop-in center where patients can shower and do their laundry.

Hackman explained that many of the patients served by the team have multiple comorbid medical disorders such as diabetes, HIV, hepatitis B or C, and chronic obstructive pulmonary disease. It is not uncommon for patients to come to the drop-in center with injuries sustained from assaults on the streets, she noted. "We'll see patients come into our office with an obviously fractured arm, a broken jaw, or a bloody face, in need of sutures and staples."

Even worse has happened. "We've had four or five patients murdered since we've been doing this," she said.

A dispute over drug use was involved in most, if not all, of the deaths, Hackman noted. Patients who are assaulted multiple times or who purchase street drugs "on credit" are at an elevated risk for an untimely death, she said.

When a patient is seriously assaulted or murdered, Hackman and Adams encourage staff to discuss their concerns and seek support for distress they may be feeling. Staff members often choose to attend the patient's funeral or memorial service, which helps them to cope with the loss.

"Having our patients end up as murder victims is an incredibly difficult thing for staff to contend with."

Staff may feel some responsibility for the patient's predicament, which can intensify their distress, Hackman noted.

One approach that benefits both patients engaging in high-risk behavior and the clinicians treating them has been dubbed "psychiatric hospice" by Adams. Clinicians must realize that if the behavior continues, the patient may end up dead, and there is little the clinician can do to prevent the patient's death, Adams pointed out.

Curtis Adams, M.D., talks about the necessity of addressing end-of-life issues with ACT team members whose patients engage in life-threatening behavior. At left is Ann Hackman, M.D., who works with Adams on an ACT team affiliated with the University of Maryland Department of Psychiatry. Ellen Dallager

Clinicians working with these patients are encouraged to talk to them about end-of-life issues. For instance, patients may wish to reconnect with certain family members or accomplish something else before they die.

"This is not a threat, as in—`if you don't change your ways you are going to die,'" Adams emphasized. "It's an opportunity for discussion about end-of-life decision making that you would have with a patient with any other illness that becomes terminal."

This approach also enables staff to feel less burdened with guilt about the patient's outcome.

The patients Hackman and Adams treat may experience chronic, ongoing trauma related to living in conditions of extreme poverty, which can also be difficult for staff.

Many have histories of physical or sexual abuse. Symptoms of posttraumatic stress disorder may be masked by a primary psychotic illness, Hackman noted. "If a patient is actively psychotic and homeless and dealing with a number of significant medical issues, it may take a while to learn that there was horrendous abuse in their pasts. But eventually we need to address this with them."

In addition, it is not uncommon for female patients to experience trauma related to having their children taken away by social services.

Wherever possible, the ACT team members try to prevent continuing trauma in patients with serious mental illness. "We try to identify patients who are vulnerable to victimization or assault and reduce their risks," Hackman noted. Long-acting injectable antipsychotic medications are useful for patients who have problems with medication noncompliance, she noted.

When a patient becomes agitated and violent and acts out against staff, Hackman said it is often helpful to review the situation among staff to discuss what could have been done differently. When the patient is calm, it is also often helpful for team members to review the situation with him or her to get the patient's perspective on how the situation or behavior could be prevented in the future.

As part of their work, ACT team members must interact with patients in areas of the city that can seem unsafe, so "staff are encouraged to trust their gut instinct" and refrain from entering situations in which they may be at risk for harm, she said.

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