By the time I was halfway through my psychiatric clinical training in nursing school, I was sure I wanted to enter this field. I loved the patients I saw and I really enjoyed learning how to provide care for them. People can see a broken leg, but they can’t always see anxiety or psychosis. If they do, they don’t always reach out to help. As a nursing student, I felt empowered to show compassion and empathy to the patients on my unit. I hope I was successful.
This hospital setting was all I had seen of the mental health field. So, as do many RNs once they’re out of school, I applied to work at hospitals. I couldn’t have been more excited when I was offered a job at the prestigious McLean Hospital. Moving from upstate New York to Boston was amazing, but knowing that I would be at one of the best psychiatric teaching hospitals in America made me feel I was really moving up in the world.
Working at McLean was a whirlwind. I saw so much in such a short time. I was constantly learning and the pressure was on. I thrived in my work and loved working with the patients there. They were having acute symptoms, and had so much to share with me. Every shift was exciting.
But there was something missing from the puzzle. Many patients who had been discharged were back within the month. Others were back in six months. I hoped that those I never saw again had a safe and happy recovery But I suspected many did not. I started to think that while my work was important, it was just the tip of the iceberg, and I began to feel restless in my role in the hospital revolving door.
After working at McLean for seven months, I started paying more attention to discharge plans. Where were people going when they left? How were they going to use the information we gave them? Would I be seeing them again soon? It was at that point that I started hearing more about a private PACT program, just 10 minutes down the street. The program was at that time called Prakash & Ellenhorn. I looked it up and couldn’t believe how so many ideas and approaches described on the website echoed what I felt was missing in the care of the people I worked with. The PACT program recognized the social component in people’s lives that is so integral to all humans.
I soon learned they were looking for a new nurse! It was the opportunity I’d been waiting for. I applied and was offered the job. There was still so much I didn’t know. True, at the hospital, I’d learned a lot about symptoms, medications and adverse effects. But I hadn’t had the opportunity to learn about people.
The PACT team changed my perspective in many ways. The people I cared for were not viewed as patients, reliant on what clinicians could provide. They were clients with autonomy, who were experiencing the hopeful beginnings of new control over lives that had felt unstable for so long.
I had found my niche. I was the nurse on a Program for Assertive Community Treatment (PACT) team. PACT is a model of care designed to keep people from being institutionalized through the revolving door of the hospital or in a series of residential programs. I learned that keeping our clients in the community meant they continued to have real lives, even if they were suffering from difficult psychiatric experiences or symptoms. Witnessing the results of this type of community integration care, which has actually been around for over 30 years, has proven to me many times that it should be available to anyone who needs it. I’ve seen so many changed lives because people were given the chance to remain outside the hospital, building relationships and finding meaning and purpose in their lives — driving forces for all people.
I find it disappointing that this model is not one typically taught in school. I would have loved to learn more about community integration work while a student. Instead, we focused on hospital level care, residential care, partial hospital care and intensive outpatient care. There wasn’t room in this very medicalized model to keep someone involved in their life and in their community, while also providing intensive wrap-around services, as PACT does. At the first signs of difficulty, people were sent to the closest emergency room, often against their will, then shipped off to programs where they were in treatment from 9-5, isolated from their families and friends, and often lost whatever traction they had in their vocational endeavors before it all took place.
This loss of traction, or the loss of one’s path in life, often correlates with psychosocial trauma, which is the loss of one’s expected role and path in life due to symptoms of mental illness or addiction. Our PACT team devotes a great deal of its efforts to relieving clients’ psychosocial trauma. Yet treaters in most other models of care ignore it or fail to successfully address it because the client has been uprooted from their home community and for that reason, is unable to form nourishing real-life connections, reclaim a life-track, and regain a social role.
For the past few years, I’ve been practicing as a Psychiatric Mental Health Nurse Practitioner (PMHNP). This role has solidified in my mind the need for more community-integrated care. I hope that insurance companies will come to understand the importance of this treatment model and will start putting their resources into prevention, rather than waiting for acute psychiatric crises before stepping in and helping their customers. Only time will tell.
