When Help Is Hard to Reach: Assertive Community Treatment

Dr. Richard Miller MD

Source: Courtesy of Dr. Richard Miller

Living with a serious mental health condition can make daily life quite difficult. When your thoughts are jumbled or you are deep in the trenches of depression, it is hard to keep track of things like bills, mail, and life. Perhaps this is a great reason why 76% of individuals experiencing homelessness in America also live with a mental health condition (Gutwinski et al., 2021).

For these individuals, obtaining recovery usually requires more than a five-minute appointment with a primary care physician or a 30-minute virtual therapy session once a week. Even keeping track of those appointments can add stress. A meta-analysis found that people living with schizophrenia miss on average between 20% and 67% of their mental health appointments (Daniels et al., 2014).

Sometimes the reason someone needs support gets in the way of them getting it.

That's why specialized, team-based approaches exist. Multifaceted care involving a psychiatrist, therapist, peers, and/or a community support specialist can empower those with complex needs to stay on track with their recovery goals.

To better understand this level of assistance, I spoke with psychiatrist Richard Miller. In addition to his private practice, Miller leads an assertive community treatment (ACT) team. Within this structure, participants have access to a crew of providers, which could include a therapist, community support specialist, psychiatrist, peer, and/or vocational counselor. They can help with everything from housing to health services to encouraging someone to find fun things to do during the day.

I spoke with Miller about the role of a psychiatrist on a team like this, as well as the benefits of this wraparound pathway.

Psychiatry and Trust

Seeing a psychiatrist can be an intimidating prospect. This is especially true for someone who might be experiencing paranoia or other mental health challenges. Yet, being able to collaborate with a provider is key to progress.

Miller starts with the objective of "trying to instill trust that my intentions are legit and that my goal is to help." He expressed the importance of genuine interest in clients, their unique qualities, and their wishes, saying, "Relationship building is what I strive for in all my appointments, whether in the hospital or outpatient clinic."

With medication, he shares, "We've got many tools in the toolbox, we've come very far in psychiatry. It's like going to a hardware store, and there are like 50 types of nails. Here, we've got multiple psychotropics—dozens—and if one doesn't help, another might."

A newer option that Miller is particularly enthusiastic about is long-acting injectable medications. These medications can be provided through a shot so that a person does not have to worry about daily doses of medication. He says, "Today, we even have long-acting injectable options available now that are given monthly, every two months, even every six months."

Assertive Community Treatment

"ACT goes above and beyond to get the client the help that they need," Miller says. One advantage is that team members play an active role in helping keep someone engaged. This could include home visits or meetings in a public space if the person is more comfortable. In Miller's words, "We come to you." When necessary, he will meet with clients in their preferred spaces in the community, when making an office visit is not workable.

He notes, "Sometimes they can be hard to find," highlighting the realities for individuals who may be facing both mental health and housing difficulties.

Family Engagement and Psychosocial Support

When a person is experiencing a significant mental health challenge, often a family member is the first to recognize the need for support.

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Miller comments that in these cases it is key to "Know where the family is coming from, the patient is coming from, and where I'm coming from—as the psychiatrist who wants to do no harm and help people--hopefully we can meet in the middle."

Therapists can also provide psychoeducation to families as well as assist individuals in exploring their experiences and moving toward their recovery goals. Specialized psychotherapies like recovery-oriented cognitive therapy are available to individuals with significant needs. These approaches focus on movement toward someone's valued goals while maintaining wellness.

Social support is also important. In many communities, clubhouse model programs exist where individuals can drop in during the day for groups, volunteering, friendship, and other meaningful activities. "There are a lot of clubhouse options," Miller says. "There are places to get support from people on a daily basis."

He ended our interview with a message of hope: "There is a lot of hope out there. We have a lot of good technology on our side."

Managing significant mental health challenges is tough. What works well for one person might not be the best route for another. A team-based approach that includes a person's support network is optimal.

To find a therapist, please visit the Psychology Today Therapy Directory.