For severe mental health cases, a team approach

On a recent morning, members of the Ramsey Assertive Community Treatment team pull up to a table to discuss some of their 95 clients.

"She hasn't been hearing the voices," one the team members says of a woman under its care. "Listening to music helps with the voices because when she repeats the lyrics it helps distract the voices. She looks really good."

Meetings like this one offer hope for the approximately 2,000 severely mentally ill people in Minnesota who are living at home. It could help allow some people with severe mental illness to disprove the stigma that surround their diagnoses: that they cannot regain that ability to lead normal lives or that they will someday have to be committed to a hospital or treatment facility.

• Related: Minnesota's Mental State

The Ramsey County team's 13 members, who include psychiatrists, nurses, social workers, vocational specialists and chemical health specialists, want to ensure that no significant detail in a client's treatment is missed.

A 'HOSPITAL ON WHEELS'

More than 220,000 people received mental health services from the state of Minnesota in 2010, according to the latest data available. The team approach, reserved for clients with the most severe mental illnesses who are able to live at home, has proven so successful that state officials are evaluating how a modified ACT team approach could help clients in prisons, and people in remote areas of the state.

"We're essentially a hospital on wheels," says Bria Grudzielanek, Ramsey County team leader. "We're able to go out into the community and see people, so we do provide the most intensive level of service next to hospitalization."

The ACT team's hourlong meeting offers a chance for mental health and other professionals to provide their colleagues with an update on every client they've visited in the past 24 hours. They work with people who have been diagnosed with long-running mental illnesses, among them schizophrenia, depression, personality disorders and bipolar disorder.

Some clients hear voices, who think their neighbors are plotting against them or who are afraid to go out in public. Some are thinking about suicide.

All of the team's clients have been in treatment through other programs, but they've been referred to the ACT team because they need more intense supervision to make those treatments stick.

CLIENT-CENTERED TREATMENT

Grudzielanek's team discusses clients every day. That's what makes its members effective, she says. But more important, she says, is how the team works with each of its clients to develop a "client-centered" treatment plan.

"We're not here to tell you what to do," she said. "We're really here to help you and support you and you get to define what that support is going to look like for you."

Practically, that means clients can live in the community -- whether independently or in assisted-living situation -- and determine their own goals. It may sound simple to some, but symptoms like paranoia or extreme anxiety -- and circumstances such as homelessness and chemical dependency -- can interfere with a client's progress.

Once a client identifies a goal, the team assists in any way possible so the person can achieve it. For example, a client who is afraid to go out in public might set a goal of going to a Twins baseball game, something many would take for granted. That means the team will help the person learn to do things like getting to the ballpark.

"What we're going to be doing is practicing riding the bus so he can get used to the bus route there and know how to get there, practice using some de-escalation techniques, things to help reduce the anxiety so he can enjoy the game when he's there," Grudzielanek says. "And we're also working with him on walking, because he wants to build up his stamina so to be able to walk around the stadium when he's there."

The need for clients to exercise comes up a lot in the team meetings. Studies have shown a connection between physical health and mental health, so ACT team members make it a point to encourage clients to exercise when that fits into their goals. It's all a part of getting clients to "own" their health -- to avoid the crises that can arise when symptoms get bad.

"We definitely are here to respond to crises when they happen, because they do happen," Grudzielanek says. "We're working with people who have really severe illnesses. But our goal is to prevent those crises. So helping people recognize possible triggers or stressors and being able to deal with those before they get to a crises situation."

GOAL: KEEP PATIENTS OUT OF THE HOSPITAL

There are 26 assertive community treatment teams in Minnesota, spread almost evenly between the Twin Cities metro area and the rest of the state. Those services cost about $12,000 per client per year -- a tab largely paid through medical assistance or insurance. For clients who don't qualify, counties will pick up the cost.

ACT teams started in the 1970s, sparked by a movement to move patients from institutions. From the start, members of such teams have aimed to treat people with what are considered severe, long-term mental illnesses in their communities.

The goal from a treatment perspective is to keep patients out of the hospital. Given that the cost of keeping a patient in the hospital is thousands of dollars a day, Grudzielanek said it's a good deal.

"We are intensive; we are available 24-7," she says. "So we always have someone on call, we work weekends, we work holidays. But it is still better to have this than someone go in the hospital and get 24-hour care and pay for that. "

After the team's daily meeting wraps up, the real work begins -- work that inevitably involves a lot of driving.

"In a year I probably put [in] 40,000 miles or more," team member Yer Lee says with a laugh. "I stopped counting."

Lee, a social worker and vocational specialist, is often out of the office, meeting with employers who are willing to consider hiring ACT team clients, and helping clients find work.

ONE CLIENT'S STORY

On a recent appointment, he met with Kris O'Leary, a client who has a strong desire to work. They've met each week for about an hour or so to work on job applications, online job searches and interviewing skills. Lee also helps his client make phone calls and arrange follow-up conversations with potential employers.

O'Leary was diagnosed 12 years ago with paranoid schizophrenia after experiencing auditory hallucinations. He believed he was possessed, that his house was haunted. That confusion and fear led him to crisis. He was committed and spent time in a state hospital and group home before beginning with the Ramsey ACT team in 2009.

Working with the team, O'Leary said, brought some stability to his life.

"They showed me the correct path and how to handle my mental illness better with medication," he said. "I've been on a couple bad medications -- one gave me fainting spells and the other one made it so I couldn't sit still. ... It's been going okay. I haven't had an episode of paranoia in awhile."

Now 37, O'Leary is doing well on his medication. He manages a bank account, works out at a gym, and -- with help from a housing assistance program similar to Section 8 -- he's been renting a small spare apartment on St. Paul's East Side. It has the hallmarks of a bachelor pad: ashtrays, skulls for decoration and rock posters on the wall. On a recent visit, he wore a T-shirt with the band AC/DC's logo on the front.

Despite a consistent work history before his diagnosis and numerous job applications, O'Leary hasn't been able to get past the interview stage over the past few months. With that in mind, he and Lee have decided to try some practice interviews. Lee plays the role of a hiring manager at Subway.

After they wrap up, Lee asks O'Leary how he thinks he can improve.

"Just be more confident when I go in there with my answers, not waste all this time thinking about an answer," O'Leary says. "Just boom, boom, boom."

"How do you think you can change your confidence, though?" Lee asks.

"Getting a job," O'Leary replies with a laugh.

"Like with the interview itself? Because you said you don't have a lot of confidence in the interview," Lee says.

"Expect the questions."

PROGRESS IS THE POINT

When O'Leary finally lands a job, he will give Lee the green light to check in with his employer about how he's doing. It's that ongoing connection that he feels increases his odds of getting where he wants to be.

"Now I'm at a place where I'm living by myself, and the only person I really have to rely on is myself," he said. "The ACT team members, they show up every once in awhile: once a week, twice a week. But pretty much it's me on my own, fending for myself."

"I'd like to get a job, save up for a car, and take myself to school, college," he said. "I'd like to move on from this part of my life. Not really forget about it, just learn from it. Look back on it, say, 'I was there, that happened to me, and I dealt with it.' Progression, you know? Progress."

Grudzielanek, the ACT team leader, agrees with O'Leary that "progress" is the point.

"Ultimately we want to work ourselves out of a job where people do not need us anymore," she said. "So a lot of what we're doing is teaching skills to people, helping them learn to manage their symptoms, to be able to stay in the community -- to be able to live in an apartment, to be able to interact with others, be able to work or go to school, and do the things that they want to do."

On average, Grudzielanek said about once a month a client graduates, or "steps down" to a less intensive program. But there also are disappointments. A number of clients have died from their illnesses, or from other medical problems.

For the team's members, sometimes success is just keeping clients alive and functioning, and achieving small victories.

"You were able to get a job, or you made it to this class, or you joined the Y, you were able to communicate with your partner," Grudzielanek said of the small successes that can help clients.

"Just things that, being able to highlight those strengths and seeing them recognize, 'Wow, I did learn a lot, I did do a lot these past six months' is super exciting. People get better. That's one of the best things, that people do recover from mental illness. That they're able to live the lives that they want to live."

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