Monday, October 01, 2007

PACT teams need AOT

Assisted outpatient treatment drastically improves PACT teams’ ability to provide treatment.

Sometimes called a “hospital without walls,” PACT (Program in Assertive Community Treatment) teams, also called ACT teams, bring critical treatment services to the patient. NAMI calls ACT teams “highly effective” and SAMHSA notes that experts consider them to be “an essential treatment option.”

What isn’t widely publicized is that PACT incorporates the state hospital function of using civil commitment to ensure treatment compliance. In fact, the PACT Manual states that the program has a “consistent record of serving involuntary outpatient treatment clients at no less a level of effectiveness than voluntary ones.”

Of course, if you live in a state with no option to use AOT, like New Jersey, PACT teams don’t have that tool. In these cases, PACT teams are powerless to help someone who refuses treatment. This is even more troublesome in states like New Jersey, because refusing clients remain with PACT even if they refuse its help. That means New Jersey citizens are paying for people to refuse the most expensive services the state has to offer – 1 out of every 4 people enrolled in PACT does not participate.

Even in the 42 states that have AOT laws on the books, PACT teams in the field do not always use it. An article in the journal Social Service Review compared two PACT teams – one team located in a state where outpatient commitment was legal, but not an established practice. The other team used outpatient commitment in about 10% of cases to require treatment participation and, in some cases, to mandate patients to take medication.

Both teams report using similar interventions to promote adherence – monitoring, listening, persuasion --- until a client becomes nonadherent at which point their practices are strikingly different.

Staff on team where AOT is used in about 10% of cases:

  • In order to avoid any potential conflict that court-ordered treatment may produce between the team and the client the team tries to treat mandated clients the same as they treat the rest of the clients, for example, by focusing on the client's own recovery goals.
  • Some clients readily accept the formal mandate in court, agreeing to comply "because they've been in the program and it means really not a whole lot different than the day before it happened."
  • Team members routinely supervise mandated clients in taking medication and remind the clients that the court order will be enforced if they do not adhere.
  • Some clients attempt to defy orders by "cheeking" medications. In those cases, the team uses creative ways of enforcing the order.

Staff on the team in state that doesn't use AOT:

  • Because they do not use outpatient commitment, involuntary commitment to inpatient treatment is the primary means of pressing nonadherent clients to accept treatment.
  • Team members reported watching clients undergo a downward spiral, because there is often a long interval between the early signs of decompensation and the clients meeting the standards for commitment.
  • They essentially play a waiting game until the client exhibits some sort of violent or self-harming behavior that warrants involuntary commitment.
  • They describe one patient who stopped taking medication and didn't want to see the team. They knew if they tired to hospitalize her, the hospital staff "can decipher in like 15 minutes that she doesn't need to be hospitalized. We just see that if she, you know, physically or willfully abuses somebody, then we can have documentation."

The PACT comparison shatters (yet again) some of the oft-repeated myths about assisted outpatient treatment.

  • Dragnet for all patients - The team used court orders sparingly, for about 10 % of clients. The vast majority of patients did not get orders.
  • Easy way out for providers - The team used traditional methods of soliciting adherence first and only used the court order as a last resort.
  • Damage to therapeutic alliance - The team found ways of preserving the relationship by working with the client's recovery goals and trying to treat them like other clients. Besides, the team that didn't use treatment orders still didn't have a therapeutic alliance because she refused to see them.
  • Mandating treatment won't work - The team reported that most clients followed the order. The team took steps to enforce the order when clients didn't comply
  • Services aren't available - In this case, these were clients who were already receiving services- that wasn't the issue. The court order provided a means for the team to encourage compliance and ensure that the client benefited from those services.
  • Limits autonomy- The teams that used medication orders were able to ensure that patients remained compliant and therefore stay in the community which offers significantly more autonomy than the hospital.
  • Court orders take too much time - It takes much less time to get a court order than it does to watch someone spiral downward - basically managing their psychosis and hoping that you are there when they do something that can get them hospitalized... and hope they don't hurt themselves or someone else in the process.

According to Dr. William Knoedler, who directed and worked as the psychiatrist for the original PACT team in Madison, Wisconsin, from 1972-1997 and currently provides consultation on and training for the PACT model nationally and internationally, “the PACT teams he works with have 20-25% of clients under a civil commitment and another 5% on probation/parole.” He explained, “Obviously, we do not shy away from use of involuntary services when called for and take seriously our charge to implement the court’s wishes.”

PACT is extremely successful. But without using AOT, it is just another excellent tool unavailable to those who are the most ill.

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