What About Assertive Community Treatment?
An Interview with PACT's William H. Knoedler, M.D.
Note: In a landmark five-year study by the Schizophrenia Patient Outcomes Research Team, 15 scientists from three major research centers reviewed current scientific evidence documenting the most effective treatments for schizophrenia. Along with appropriate and careful use of antipsychotic medication, the study endorses the comprehensive approach of assertive community treatment as a treatment model of proven benefit to people with schizophrenia.
For this article, the Advocate interviewed William Knoedler, M.D., who directed and worked as the psychiatrist for the Program of Assertive Community Treatment (PACT) in Madison, Wisconsin, from 1972-1997. He provides consultation on and training for the PACT model nationally and internationally. Currently, Dr. Knoedler is the staff psychiatrist on two PACT teams, the original team in Madison, and a rural team in Green County, Wisconsin.
NAMI: Dr. Knoedler, who benefits from the PACT model?
W.K.: It is suited for people from their late teens to their elderly years who have a severe and persistent mental illness such as schizophrenia, bipolar disorder, or schizoaffective disorder. Some people with obsessive-compulsive disorder and some who are not helped by traditional outpatient models benefit, too. Assertive community treatment can reach people who don’t keep office appointments, for example. The traditional case management framework—directing people to various services that they then seek out on their own—fails people who need services adapted to meet their unique needs. People who may be turned off by bad past experiences with treatment or have limited understanding of their need for help are often helped by PACT.
NAMI: What brought PACT into being? Do the problems that resulted in PACT still exist?
W.K.: In the late 60s, early 70s, simple observation showed that hospitals were being depopulated. People with severe mental illnesses were being discharged into communities with much less than adequate services. Some hospitals closed; others reduced the number of patients they treated. But time was not taken to ensure that there was an adequate transfer of money and services to community programs. This is the story of deinstitutionalization: people were living poor lives in the community and cycling back to the hospital, a phenomenon often referred to as "the revolving door."
he community mental health services that were set up often were not appropriate for people with severe mental illnesses. Even though serving people discharged from state hospitals was an original goal, community mental health centers actually became therapy centers for more healthy people. This distressing situation led people to ask, "What happened? Why isn’t community treatment working?"
Since the 1960s I’ve seen more people with severe mental illnesses live with their families, become homeless, abuse drugs and alcohol, and go to jail. People got some help when they were in crisis and possibly some case management, but comprehensive care did not exist. This was the scenario that led several courageous people—Arnold Marx M.D., Leonard Stein, M.D., and Mary Ann Test, Ph.D.—at the Mendota Mental Health Institute in Madison (one of the two Wisconsin state hospitals) to attempt to treat people who were trapped in the revolving door more effectively.
Now, 26 years later, with increasingly effective mediations for severe mental illnesses, many people don’t need the comprehensive level of services provided by assertive community treatment teams. But, unfortunately, my observations about treatment inadequacies in the late ‘60s and early ‘70s are still valid today. The public continues to ask "Why are people with severe illnesses not getting help for their problems with mental illnesses?" Mental health systems still are not tailoring services to meet the needs of people least able to function in the community, those who are the most costly in financial and human terms.
NAMI: We’ve talked about who PACT is for. Can you now briefly describe assertive community treatment?
W.K.: This may sound like a very obvious approach, but the founders of PACT tailored the way services are delivered to meet the needs of people with severe mental illnesses. With an assertive, persistent, practical approach, they saw to it that consumers actually received services in a continuous fashion over a number of years. The team doesn’t wait until a person comes to the office. The majority of services are delivered where consumers live, work, and spend their leisure time, not in the program office. The team helps consumers manage symptoms of the illness; they provide practical on-site support in coping with life’s day-to-day demands. With the team approach, even with staff turnover, support can be consistently provided over time. The consumer is a client of the team, not of an individual staff member.
Treatment, rehabilitation, and community support services are each tailored to the individual’s needs. PACT provides up-to-date medication, and staff help people manage their medications, gain employment, and learn how to socialize and carry out a variety of tasks to live in regular housing alone or with a roommate. When a consumer can’t do something on his or her own, the team steps in to help. Staff members help consumers get financial entitlements, housing, and non-psychiatric medical care. They oversee all medical care, including primary care and family planning. The team is consistently there for the consumer and family members, and the "one stop shopping" provided covers all aspects of community living.
NAMI: Who staffs a PACT team?
W.K.: The majority of staff are mental health professionals. A psychiatrist and psychiatric nurses make up the medical "team within the team." Master’s level social workers, a vocational specialist, an alcohol and drug treatment specialist, plus paraprofessionals make up the rest of the team. Team members serve both as specialists and as interchangeable generalists. We want people on the staff who are practical and who can think. Consumers or ex-patients sometimes fill professional or paraprofessional positions on assertive community treatment teams, and some teams have peer-counselor positions.
NAMI: What is the role of the psychiatrist on the team?
W.K.: The role of the psychiatrist is a critical aspect of the assertive community treatment approach. Unlike in traditional community mental health structure, the PACT psychiatrist is a full team participant, not a consultant to the team. The psychiatrist doesn’t just sign off on treatment plans; he participates in treatment planning, staff meetings, and teaching staff how to carry out treatment. In addition to the traditional prescribing and monitoring of medications and conducting therapy and crisis intervention and coordinating inpatient care, the psychiatrist acts as a kind of general practitioner as he or she provides and monitors both psychiatric and non-psychiatric medical care for the consumer.
I spend a quarter to a third of my time in Madison meeting with consumers in the community and more than 50 percent of my time out of the office in my rural program. I can get a better sense of a person’s strengths and his or her real environment when I am outside of my office.
Usually the assertive community treatment team leader is a master’s level social worker who works closely with a psychiatrist who provides clinical supervision, but sometimes the psychiatrist is the team leader. A psychiatrist as the team leader may be desirable in a complex urban environment where homelessness and alcohol and drug abuse are very common.
NAMI: Can you say more about the "one stop shopping" approach?
W.K.: I would like NAMI members to understand that much of the strength and greater effectiveness of assertive community treatment comes from this approach. The team’s direct, integrated provision of services brings medical/psychiatric treatment, rehabilitation, and community support services to severely ill consumers who otherwise would receive little or no care unless they were in a crisis that the community could not disregard. The team also deals with legal issues. When a consumer is arrested for minor offenses, the team intervenes. When a consumer is in jail, the team continues to see him or her, which often facilitates an earlier release.
The one-stop approach is especially effective in three areas: vocational services, alcohol and drug treatment, and helping consumers—usually women—develop skills as parents.
NAMI: How does PACT work with family members?
W.K.: We involve families directly and early on. We seek family suggestions about how to help the consumer. The psychiatrist and other team members meet with the family to teach them about their loved one’s mental illness and its treatment, and we offer practical suggestions for interacting with the ill family member.
We encourage and try to help consumers live in their own housing, if possible. This level of independence may take some time to accomplish, but having housing separate from parents (while remaining well supported by the PACT team) can make it easier for the consumer to relate to his or her family as an adult. Whatever happens, the team will be there supporting the consumer and family.
NAMI: How can NAMI members get assertive community treatment started in their communities?
W.K.: I think families and consumers are the most effective advocates for this approach to treatment. They must educate themselves about the model and then meet with those who decide what psychiatric services are provided in their communities—the county mental health services board, state department of mental health, local community mental health center, and local and state political leaders. Advocates can point to the recommendations in the Schizophrenia Patient Outcomes Research Team (PORT) study, for example; and they must be prepared to anticipate and answer frequently asked questions. The NAMI national office and the NAMI state offices that have succeeded in getting assertive community treatment are resources. Invite reporters to meetings with decision-makers to focus media attention on the fact that there is well-tested, effective community treatment for people who are perceived by the community as the most difficult to serve.
Policy makers may be concerned about cost for an assertive community treatment program. Balanced against hospital and jail costs, assertive community treatment is no more costly—and usually less expensive—than the usual community care for people with severe and persistent mental illnesses. It certainly is more effective and more humane.
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