New Britain — Timothy Sacerdote’s morning medication run was nearly done, without a hitch so far. He’d visited four clients, opened the combination locks on the boxes of medication in their homes and handed them pills while chatting about how they were doing, whether they’d be coming to group, and, in the case of one man, buying a cellphone.
But there was a problem brewing: Another client was facing eviction from his apartment and fuming about it. Sacerdote and Laura Magisano, his team leader, would be stopping by for his medication later in the morning, but first they had another client to see. As Sacerdote drove, Magisano worked the phone, trying to buy them time.
“Tell him Laura’s looking forward to seeing him,” she told a colleague, hoping it might calm the client down.
The unexpected situation was typical, but little else about the morning was routine. There’s no such thing as a normal day for Sacerdote and Magisano, part of a team that provides intensive support to people with serious mental illness who live in the New Britain area.
“You get to work and the gun goes off for this marathon-obstacle course-speed race,” said Magisano, the program coordinator. “It’s absolutely nuts and it’s fantastic at the same time.”
Known as an Assertive Community Treatment Team, or ACTT, they serve about 75 clients, most of whom have psychotic disorders. The team includes a nurse, psychiatrist, advanced practice registered nurse, vocational specialist, case managers and therapists. They work to give clients the supports necessary to live in the community, handling routine issues and crises — giving clients medications, providing rides and connections to job training, working on budgets and helping them learn how to grocery shop, handling housing issues or psychiatric emergencies.
The model emerged decades ago as institutions closed and people with mental illness moved into communities. Evidence suggests it works, but it’s expensive (though less costly than institutional care). Connecticut now has three ACT Teams, each of which costs about $1 million, funded by the state Department of Mental Health and Addiction Services. Commissioner Patricia Rehmer has asked for money to run additional ACT Teams and said she’d like to see them statewide.
Some of the clients have lived in Connecticut Valley Hospital and other now-closed state institutions. Some previously lived in group homes. Some have accepted the supports and are as stable as they’ve ever been. Others have more tenuous situations, struggling with substance abuse or more active mental illness and are more wary about treatment. Those served by the ACT Team represent a small subset of people with mental illness who need the intensive supports for at least some time.
For most people, something like a late electricity bill isn’t a major hiccup; you pay the bill and move on, said Paul Dalessio, director of assertive community programs for New Britain-based Community Mental Health Affiliates, which runs the ACT Team. But for someone living with a psychotic disorder or major depression, “It could just blossom,” he said, affecting every facet of his life.
The team members meet every morning to discuss how clients are doing and communicate with each other almost constantly to make sure any problems that come up get addressed.
ACTT is more an art than a science. It can take months to earn the trust of clients, some of whom have paranoia or don’t deal well with change. Therapists meet with clients in their homes, at Dunkin’ Donuts or while walking in the park, wherever they’re comfortable. Magisano has one client who doesn’t make eye contact. They take drives together.
Sometimes team members make a connection by finding what the person is passionate about. An art show last year drew out some clients, showcasing talents the team hadn’t known about.
“We help them live with their illness, but their illness is not their life,” Dalessio said.
A landlord intervention
As they drove to meet the client facing eviction, Magisano hoped she could defuse the situation. They’d had a strong bond since she’d done individual therapy with him two to three times a week. She had taken him to the emergency room when he needed detox. He struggles with associations and his language sounds like “word salad,” but while other people might tell him he was making no sense, Magisano would let him talk.
He was still angry when they got to his apartment, a single room with walls covered in his artwork. Magisano listened as he blew off steam, while Sacerdote got out his pills. He said the landlord wanted him out because of people he’d had in the apartment. “Is there someone specific that set this off?” Magisano asked. The client said the problem was what other people had been saying. “Like hearsay?” Magisano asked.
After a few minutes of talking, the man was less agitated. He told Magisano he’d probably go out for part of the day. “When you come back here, can you just lay low so I can deal with it?” she asked him.
The client kept talking as Sacerdote headed for the door. Magisano told him they’d need to get going, but kept listening as he continued.
“Sometimes you gotta keep the train moving,” Sacerdote said as he exited the apartment, on the way to the next client.
Trust in the team
Claudette Pirruccio got to know the ACT team more than two years ago, when she was still in a state hospital. The team helped her find a place to live when she got out. She’d been nervous about the transition, but it went smoothly, she said, because she knew the team.
“I say, ‘My doctor makes house calls!'” she said with a smile.
Pirruccio agreed to speak with a reporter and have her name used. The other clients described in this article gave permission for a reporter to observe their visits but not use their names or identifying details.
Pirruccio keeps busy. She’s on the board of the social club run by clients of the ACT Team’s parent agency. She testifies about mental health issues at the legislature. When she had a problem getting benefits from the state Department of Social Services, she went directly to her state representative. Her efforts ended up helping other clients get problems with their benefits fixed too.
That’s not to say it’s been easy. Pirruccio has long struggled with depression and has attempted suicide many times, including since she became an ACT Team client. She’s noticed that if she doesn’t see the people on the team regularly, “I start falling apart” — getting depressed, and getting thoughts in her head that could become suicidal.
But her hospitalizations have decreased since she’s been with the team. She used to see a life coach, part of the team, for six hours each day; now it’s down to five hours, twice a week. Pirruccio said she trusts every team member, which is critical.
“If I’m not feeling well, I’m able to tell them because I trust them so much,” she said in her apartment. The smell of chocolate permeated the place; she’d baked brownies for Sacerdote and Magisano’s visit.
In a typical therapist-patient relationship, accepting food from a client is considered to be crossing a boundary, but the ACT team has different boundaries that require constant assessing. A client might want to give a therapist a hug or say he loves them.
“Sometimes we are the only people in their lives,” Magisano said.
‘It’s their reality’
Historically, an ACT Team client in Connecticut would be a client for life. But that didn’t fit with the orientation of the state’s mental health department, which uses the premise that people can recover from mental illness.
So ACT Teams now work with the expectation that people will eventually transition to less intensive services. Some have already “graduated” from the New Britain ACT Team, although some have come back. And Magisano and Dalessio think that a handful of long-term clients will remain with the team for life. It’s all they’ve known in the community. Even if they’re psychiatrically stable, other medical problems increase as people age, and nursing homes might not be appropriate or available.
One of their long-term clients is a woman who has command hallucinations that tell her to sit or stand. It took a long time to figure out that’s what was happening; she would move up and down seemingly at random. Magisano figured it out one day when she asked the woman if she wanted to sit or stand and she answered, “I want to sit.”
The team doesn’t refute a hallucination. “It’s their reality,” Magisano said. But if the woman wants to sit and the voices are telling her to stand, she might say, “You do what you want to do and we’re here to support you.”
The client smokes marijuana because it makes the voices she hears quieter.
Magisano and Sacerdote are more than a little fond of her. Each of them has known her since they started working there.
“When are you coming back to group, Missy?” Magisano asked as she took her pills.
Soon, the client said. “It’s just been a little rough on me from the head to the toes.”
“I just can’t not smile at her,” Magisano said later, as she left the apartment. She scraped her shoes on the sidewalk, hoping to dislodge any bugs from the woman’s building that might have used her as a ride out.
Dealing with housing and landlords is a major priority for the team, by necessity. Some clients have burned bridges with their families or have none. They have little money to live on. And affordable housing in the more preferable buildings is hard to come by. One clean, quiet building for elderly and disabled residents has an eight-year waiting list.
“We don’t want them to lose their spots,” Magisano said.
The team has a strong relationship with one landlord who identifies himself as a slumlord. It’s easy to get a client into one of his places because he doesn’t do background checks or require written leases or security deposits up front. If there’s a problem with a client, he’ll call the team instead of immediately pursuing an eviction.
“He’s really workable,” Magisano said. “He’s very kind.”
There’s a trade-off, though: the living conditions. There are drugs and bugs. Sometimes they’ve had to call the health department. ACT team members don’t wear pants with cuffs to avoid walking out with a bedbug or roach. For one of the team’s clients, a former crack smoker, one of the slumlord’s buildings was the alternative to homelessness. But once there, he relapsed.
At one building, Magisano and Sacerdote make a point of taking the stairs because it’s not uncommon to find urine or feces in the elevator. Magisano tiptoed around a splattering of vomit on the staircase. “I can honestly say that’s been there for probably two weeks,” Sacerdote said.
The ACT Team handles money for some clients, writing checks to landlords and Connecticut Light & Power, and doling out spending cash.
Many clients can’t read and rely on cashiers to get the right change, making them easy victims. It’s not uncommon for a corner store to add an extra zero when swiping their food stamp card for a $20 purchase, Sacerdote said.
Sometimes clients need to find creative practices to maintain themselves, which can be costly. A broke person who needs food could have to promise $3 for a 99-cent can.
With some clients, team members work on grocery shopping, talking about sales and nutrition. Because some don’t have the best executive functioning and struggle with impulsiveness, it takes some work to not buy the first item they see. Sacerdote tries to stress that by comparing items, they might find one that costs half as much, letting them buy twice as much for the same price.
It’s about relationships
Rehmer, the state’s mental health commissioner, sees ACT Teams as “the other side of the coin” from getting court orders that require people living in the community to get treatment. Connecticut does not allow so-called outside commitment, but some people are advocating this as lawmakers look to make changes in response to the mass shooting at Newtown’s Sandy Hook Elementary School.
She believes ACT Teams work in part because they’re built around relationships.
“Medications are great. They can really help people with symptoms. Getting people jobs is really important. Getting people in supportive housing, or housing, is really important,” she said. “If you talk to individuals and say, ‘What had the biggest impact on your recovery?’ all of those things will be a part of it. Their peers will be a part of it.”
“But I would venture that most individuals will identify at least one person in the treatment system, maybe 10 years ago, maybe that they’re working with now, maybe somebody that they had one interaction with, that somehow impacted their recovery.”
“And so allowing those relationships to develop is really important,” Rehmer said. “The ACT Teams are really intensive in that way.”
Sometimes people fall through the cracks in the system, despite the team’s best efforts. Sacerdote had a client who was taken to a hospital emergency department but let out. Hours later, he was killed by a hit-and-run driver while walking on a highway.
Pirruccio, the client who made brownies, worries about the shortage of psychiatric hospital beds in the state, and said the gridlock means some people having psychiatric crises stay in emergency rooms for days, sometimes on stretchers. Some will tell the triage nurse they’re fine, even if they’re not, just to get out, only to come back after attempting suicide.
What is success?
Rehmer’s department has started requiring that the three ACT Teams it funds collect data on certain outcomes –whether clients have improved functioning, gotten employment, maintained stable living, been readmitted to ACT after discharge, and successfully completed treatment. The first batch of data is not yet available, according to the department.
How does the team measure success?
“Success might be brushing their teeth for the first time in six months,” Magisano said.
Or taking a shower for the first time in two weeks, Sacerdote said.
It might be having a client’s money last from Monday to Wednesday, not Tuesday. Or having hospitalizations that are further and further apart.
“More independence overall, whatever it means to them,” Magisano said.
Dalessio, a former ACT Team member who still fills in when needed, gets emotional when recalling one trip he took with clients a decade ago. It was a February night with snow on the ground. He drove them to a beach in Old Saybrook and said, “Everybody out.”
They walked to the water’s edge and Dalessio told them, “As loud as you can, I want you to scream, ‘I am alive!'”
Why did he do that?
“We experience life every day,” Dalessio said. People without mental illness go to the beach, or to the mall, and might think little of it.
“These folks, some have lived miserable lives and have been shunned” by their families and society,” he said. “They have every right to experience life as we do.”
“I just wanted them to know that it’s OK to be you. Yeah, so you have an illness, but a diabetic has an illness, too, and they live.”
Follow health writer Arielle Levin Becker on Twitter @ariellelb.