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
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
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
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.
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
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
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. ▪