Allowing the Mentally Ill a Life of Their Own
Supporters Say Patients Prosper and State Reduces Hospital Beds in Strictly Supervised Program

By Chris L. Jenkins
Washington Post Staff Writer
Thursday, February 28, 2008

Rafael Rivera sat comfortably in his neat, modest apartment off Route 1, talking to his caseworker, Carlos Estrada. Seated nearby was Parnell Cornet, a psychiatrist.

"So we're going to get you a job in the coming months, right? Looks like you're almost ready to work again," Estrada said, looking around the apartment.

Rivera nodded and replied in Spanish that he was ready. He had just moved in to the apartment, and he was eager, at 56, to start a new life.

"Well, we're going to do everything we can to make that happen," Estrada said. "It's up to you."

Rivera has lived with bipolar disorder and other mental illnesses for nearly 40 years. He was in a state institution for several weeks, hoping to recover from the debilitating confusion and illness that prevented him from taking care of himself. He had been left by a longtime companion to fend for himself in the fall, Estrada said, and soon a friend had Rivera taken to a hospital.

The daily one-on-one contact by Estrada and Cornet is part of an intensive program to help the severely mentally ill such as Rivera live on their own. The state-funded Program of Assertive Community Treatment seeks to move those with serious and persistent mental illnesses back into their communities and support them with round-the-clock services to help them be self-sufficient.

"The doctors in the hospital, they wanted to control me," Rivera said in Spanish with Estrada translating. Living outside, he said, allows him to "look for a future."

The PACT program was developed in Wisconsin 35 years ago and is considered one of the most effective ways to help those with significant mental ailments live outside of hospitals and within the broader society. Many mental health experts consider the program the next chapter in the decades-long effort to move people with mental illness out of institutional settings by giving them the structure they need. Supporters often call the programs "hospitals without walls."

"It gives people who have these illnesses a chance to live [with] some kind of normalcy," Estrada said, as he left Rivera's apartment. "We give them the opportunity to control their own life. We're just here to help."

Many of the participants in the program include people who have frequent episodes of very severe symptoms that are difficult to manage or who suffer from symptoms that never go away.

Their condition means they often have spent extensive time in hospitals or living on the streets. They often have abused drugs or alcohol or have been in trouble with the law.

State records show that about 77 percent of state clients in the 16 PACT programs throughout Virginia have schizophrenia. The majority have come from state hospitals after an average five-year stay.

Across Virginia, the programs are hailed for helping mentally ill people stay out of hospitals permanently. Virginia used 1,517 beds in mental health facilities last year, 107 fewer than the year before, according to state statistics. In addition, more than 85 percent of the state's 1,487 PACT clients were reported to be in stable housing last year and had not been arrested.

"The model is that we allow the client to be the center of the treatment," said Jean Hartman, director of Fairfax County's program. Arlington County also has a program.

As with most programs that seek to help the mentally ill, PACT is controversial. Although the National Alliance for the Mentally Ill calls the program "highly effective," others have concerns.

Some critics say that PACT teams rely too heavily on medication and do not offer enough long-term alternatives.

"We want to have a life of richness and meaning, and in many cases, these teams aren't going beyond making sure that people take their medication or are trying to help them get some low-level job," said Diane Engster, president of the Northern Virginia Mental Health Consumers Association, an activist group based in Fairfax. "They say they are consumer-centric, but that has to be more than just rhetoric."

Other activists, who push for giving states the power to force some mentally ill people into treatment, said that the program's potential benefits are limited because in many states, including Virginia, officials cannot force treatment, even if it has been court-ordered.

What differentiates PACT from conventional mental health programs is the size of the support team. The PACT team is usually 10 to 12 practitioners -- psychiatrists, nurses, mental health professionals, employment specialists and substance abuse specialists. Teams can include a mentally ill person in recovery who can share experiences or a family member of a mentally ill person.

The Fairfax team's day starts with a group discussion about each client. Hartman calls out each name, and either a nurse, caseworker or psychiatrist will update the group about how that person is doing.

Rather than having clients come to an office or clinic once or twice a month, team members arrange their schedules around the clients' needs. This often means outreach workers visit and spend time with their clients every day, making sure they have taken their medication and gone to their appointments. Team members also counsel clients about issues in their lives.

Virginia started its first program in 1999 and has slowly funded additional programs. Part of the reason for the incremental pace is the cost. Because each program maintains a ratio of one client to 10 staff members, each PACT team costs about $1 million a year. A team's caseload cannot exceed 100 clients.

Some mental health programs limit how long a client can receive services. PACT has no such limit. The team is there for as long as the client needs it.

Mike Yankey and Raymond Reese are roommates who live a short drive from Rivera. They are able to get on a bus and make their way around, but on a recent morning visit, they are not as able as Rivera to engage in conversation or articulate their needs.

They have shown progress, however, in being able to live on their own and care for themselves. And they can appreciate life's simple but important pleasures found outside of a hospital.

"Being able to eat your own meals, eggs, meats, stuff like that; it's better than being in a hospital," Reese, 45, said. "I like the freedom."