An interview with Ross Ellenhorn
What inspired you to place such a strong emphasis on a Program for Assertive Community Treatment (PACT) methodology when you created Ellenhorn?
When we started this company 20 years ago, there wasn’t anything out there in private-care pay that addressed the enormous gap in treatment between hospital-level/residential care and limited care at an outpatient clinic. That was a real problem, because the most intensive care should take place where people manage and live their lives. And when I say there wasn’t anything out there, I really mean it. There were no intensive outpatient programs, no coaching or companion services, no case management, no supported housing, employment or education programs etc. These kinds of psychosocial-rehabilitation services and community-integration programs, which have been proven over and over again to be the effective ways to help people who are experiencing significant psychiatric events, were happening all the time in publicly funded community mental-health centers, but not in the private-pay sector.
Now that there are all kinds of private-pay options available to fill the gap to which you refer, do you still think that the PACT model is the best form of this kind of care?
I absolutely do. A true community-integration program does the majority of work outside the office and in the homes, communities, schools and worksites of its clients. Unfortunately, most of the programs that now offer intensive outreach services in such locales kind of miss the point of those services. Their outreach is mostly being conducted by individuals with little serious clinical training whose chief aim is to get each client to treatment by assertively pushing them to go, and to provide some level of surveillance of the client’s whereabouts and well-being in order to report back to clinicians and family members. Both these things aren’t really treatment, and they typically don’t work. People don’t engage in personal change when they are coerced to do so, and they don’t trust treaters who are expressing distrust in them, i.e., surveillance. That’s not just my belief: It’s what the research on change tells us. True PACT treatment takes place in the community and provides actual therapies outside the office, but, more important, it utilizes clinically trained professionals that help a person reengage in things that give them a sense of pride and effectiveness in the world.
How does having all providers, including the psychiatrist, on the same team impact the quality of care that a client receives?
At its core, community mental-health care is about providing “continuity of care,” which means that a program sticks with each client during all phases of their recovery and growth, and that there is a team of people who take responsibility for each client’s care—not a long list of separate providers. PACT is often referred to as a “hospital without walls,” and the reason this term is used is because of the intensive communication that takes place between each multidisciplinary team providing client care. In fact, every team meets every day in order to review the previous 24 hours in their client’s journey. So, not only is PACT multidisciplinary it’s highly communicative, and, from this, truly integrative, since everyone is regularly together and thinking about the client in a way in which all voices in the room are heard.
What challenges do clients face when their care is “piecemealed” between different providers or organizations, and how does Ellenhorn’s PACT model address these gaps?
That list of challenges is extensive, but the main answer to this is actually reflected in part of your question: Care that is piecemeal is always in danger of fracturing. This is even more of a threat when a client with complex and multidimensional problems is struggling with how to accept help. In other words: the typical client. Fractured care disempowers clients because clinicians tend to communicate most when a client is having a tough time; it’s surveillance more than therapy.
We live in a disturbed and unproductive world right now in which therapies are increasingly mechanical and supposed experts use certain tools for certain problems. If you adhere to this way of thinking, for which there is little evidence of effectiveness, finding a bunch of specialists sort of makes sense (like how you might see a bunch of specialists for different physical problems). The issue? Therapy must begin with a sense of containment, warmth and care—all well-endorsed by research—and with a willingness to try and understand the perspective of the person seeking help, which has been scientifically proven to help people on their road to change. People need a sense of group recognition—a sense that the group is working closely together to understand their perspective—and the real feel of a well-coordinated team that is cheering them one. You can’t get that in fractured care.
Coaching and companion services may seem a lot like PACT services, but they are very, very different. They lean toward keeping an eye on the client, which is surveillance, not therapy, and on being, well, a companion, i.e., someone to hang out with, which isn’t therapy either. Everything in PACT has a therapeutic component, and that’s why most of our outreach is done by trained clinicians. They are not there to drive clients to appointments, per se: They are the appointments.
Last month marked the anniversary of the Community Mental Health Act, which was created to decentralize mental-health care and integrate it into community settings. How does Ellenhorn’s approach reflect that vision, and in what ways do we still have work to do to fulfill it?
The Ellenhorn approach reflects the vision of community mental health in that we are the first program in the United States to take a community mental-health model and offer it on a private-pay basis. Community mental-health methods are the main way people are served in the United States and are the most researched, yet these methods—most of which are focused on returning a client’s sense of social value—are horribly missing in the private-pay sector. In this way, people who can afford to pay for care are being strangely neglected, since most of their care is focused on treating psychiatric symptoms instead of their social well-being. And that, I’m afraid, really doesn’t work because a person’s motivation to engage in treatment and address their problems depends on feeling that they are worth doing so, and that they have plans to strive for in the future.
Basically, you can’t be successful in any kind of therapy without having some sense of purpose in life. Community mental-health programs do this through things like supported housing, education and work models that provide clients with the right kind of support outside treatment. At the top of all these methods is the model that provides an entire treatment team that is mobile and ready to help get people back to life. That’s PACT. And, I’m telling you right now, PACT is not just about coaching or companionship or therapy in a person’s home. It’s about providing a large multidisciplinary team that meets regularly and provides mobile services in the community—because that’s where people prosper and change.
