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.
By William Knoedler, M.D. interview by NAMI
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."
The 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. READ MORE