How Ellenhorn’s PACT Model is Built for the Pandemic

At Ellenhorn we use a model called PACT to organize the way we provide care. PACT is the most researched evidence-based model for the care of people diagnosed with severe and persistent mental illness. This approach to care is especially effective for individuals who are reluctant to engage in treatment.

70 percent of our PACT teams’ contacts with clients happens outside the office and in the community and homes where clients live. Meanwhile, our PACT team providers meet daily and also communicate throughout each day on ways to shift the care of their clients as needed.

PACT is a single-source model, in which each client receives all their care from one multidisciplinary team. This leads to highly agile and adaptable care that responds to the ever-evolving nature of human beings. In this way, PACT is an organic model that can grow and change in response to the ever-changing nature of people, as opposed to an industrial model in which treatment is offered in one-size-fits-all assembly-line fashion.  

Now, six months into the coronavirus pandemic, we are convinced that PACT is the best professional model of care for us to use with people experiencing complex psychiatric events, and especially for individuals who are reluctant to engage in treatment. Here’s why:

Organizational Agility

As long as there is a pandemic, the number one requirement for all health care organizations will be for organizational agility in the face of new and changing recommendations and mandates for keeping safe and faced with a virus with an unknown course. Our adherence to PACT prepares us for that challenge, since our model balances significant long-term plans for clients with the understanding that teams must be ready to respond to the inevitability of crises with ad hoc immediate innovations.

As a result, we are able to shift our care immediately to adapt to the course of the pandemic, providing in-person interactions when we can, then immediately turning to more virtual care when that’s necessary due to a reemergence of the virus or new scientific information. We don’t need to create blanket policies about providing care virtually or not; rather, we can adapt to changes on a dime. What’s more, we can do this while remaining focused on accommodating the unique needs of each client.

Our mission to be as agile as possible also means our care is highly individualized. It is much more personalized than care provided in a clinic, or at a residential or group setting where treatment is offered in bulk and in a more regimented, scheduled manner. Ellenhorn’s individualized care continues during the pandemic.

Truly Individualized Care

Like most of us during the pandemic, clients of psychiatric care are becoming more socially isolated and increasingly disconnected from their social and family networks. They are hungrier than ever for the experience of being known and understood by others. That’s difficult to fully achieve in a group therapy session on Zoom. In contrast, most of Ellenhorn’s treatment is provided one-on-one by clinicians focused on the client’s recovery in multiple key aspects of their lives and who aim to understand each client’s unique strengths and barriers.

The term individualized care is often bandied about by mental health and addiction programs. For such programs, “individualized” means choosing groups and/or techniques that best match a client’s cluster of symptoms and complaints from a menu of choices. At Ellenhorn, we think of individualized treatment differently, seeing it as a form of care that views each client as highly original and deserving of treatment that approaches them as much more than their symptoms. That approach requires significant flexibility and ingenuity regarding how treatment is provided.

Truly individualized care is focused on one important goal: a collaborative relationship between the client and his or her treaters. Research on therapeutic change increasingly shows that this kind of relationship between clinician(s) and client is the central source of recovery. In fact, even applying best practice procedures has little effect if they are deployed without first building a collaboration. A collaborative relationship results from interactions based on seeing the client fully: understanding their dreams, their talents and their purpose in life.

During the pandemic, our clients need collaborative relationships more than ever, ones in which they feel that someone is by their side, helping them navigate the challenges ahead. As much as possible, we continue providing this one-on-one, collaborative form of care in person.

The Safest Means for One-on-One Contact

Growing scientific evidence reveals that the coronavirus is mostly transmitted through the air. That means that congregating with groups of others inside — especially in situations where there’s a lot of conversation — puts individuals at the greatest risk. That’s why bars, worship services and any large indoor public event are identified by experts as potential hot spots or super-spreader sites. Without extreme precautions, in-person group therapy fits within this category.

We are able to meet with clients in person in the safest manner.  Wearing full PPE, our clients wearing masks, we meet one-on-one, outside as much as possible, and six feet apart. This approach puts the client and clinician at minimum risk; close, if not lower than the risk of walking outdoors with a mask on.

Treating Psychosocial Trauma and the Goal of Psychosocial Recovery

We believe that most of our clients suffer from what we call psychosocial trauma. This is damage to their social being caused by the loss of life-dreams due to the onset of psychiatric experiences and by their treatment in more industrially oriented facilities. Recovering from this trauma typically requires direct care in their daily lives, from support in preparing meals and trying out leisure activities to taking a class and finishing a report for work. That kind of one-on-one care happens outside the office.

Breaking Through Myopia 

Mental health treatment is historically myopic, viewing the world from a certain perspective without reflecting on whether this perspective has its own problems. That myopia is particularly prevalent when it comes to clients who have been hurt by mental health systems and are thus afraid of trying again, and who (in many ways, rightfully) don’t trust the help they are offered. Staying within the walls of our clinics and residential programs and viewing these individuals as dysfunctional because they won’t accept the regimented help we offer, we continue to poorly serve them. In fact, our profession has developed pejorative terms for such individuals: They are “treatment non-compliant,” “treatment-resistant,” “difficult to engage”; while little thought is given as to whether the systems we’ve created are engaging. The neglect of people who don’t want or don’t respond to regimented care continues during the pandemic, as programs reclaim their “best-practice” mantles via virtual care without recognizing the long list of clients who refused to engage in regimented care from the start, their refusal of services now as easy as a finger on the “power off” button.

The Ellenhorn approach to PACT is built to treat these individuals, even during a grave public health crisis.

Assumptions, Certainty and Fear: How non-Mentalizing can contribute to social injustices

We all make assumptions about race, ethnicity, religion, gender identity and sexual orientation…which can harden into certainties…then fear.

How can Mentalization prevent or undo that process?
On July 15th, a webinar entitled “Assumptions, Certainty and Fear: How non-Mentalizing can contribute to social injustices” was presented jointly by Shelly Simpson, LICSW, Lead Clinician at Ellenhorn and Matt Estey, LCSW, Program Director of Menninger 360.
Mentalizing is the mental act of trying to understand your mind or the minds of others by thinking about and interpreting behavior with curiosity. To mentalize, we hold in mind the needs, desires, feelings, beliefs, goals, purposes of someone else and the reasons why they (or we) might be acting or responding a certain way.

When we feel fearful, anxious, certain or act based on assumptions, our ability to mentalize is compromised. We move into a non-mentalizing mode where there’s little room for perspective and curiosity. This non-mentalizing stance makes way for historical and current social injustices.
Today, we see non-Mentalization happening in abundance — the murder of George Floyd clarifying the horrors that occur when we are blind to the experience and humanity of others, and how oppression runs its course through dehumanization. Making assumptions first, without considering another’s experience, is a common event in all our lives, but it can become monstrous when combined with power and force. In many ways, the slogan and movement of Black Lives Matter is a call to hold in mind the particular struggle and often danger of being black. 

A non-Mentalizing stance is not only happening in the world at large — it’s happening in our offices. As mental health providers, we have blind spots and enter this work with our own assumptions and certainties. To address this in the workplace we must encourage curiosity and the practice of circling back to understand our missteps. We need to accept and not deny the reality of others when they express how our blind spots have impacted them. The rewards can be transformative: We enter into conversations in which we learn, change, and become better at understanding the minds and experiences of others.
Ellenhorn uses Mentalization in clinical work and on treatment teams. We offer Adaptive Mentalization-Based Integrative Treatment (AMBIT) to help clients who experience epistemic mistrust, disorders of self, or attachment-related issues. Ellenhorn also offers Mentalization-based family and individual therapy. In addition, Ellenhorn clinicians and leadership encourage using Mentalization in team meetings, supervision, and interactions among co-workers. In these situations, Mentalization brings to awareness and helps us correct missteps and microaggressions with a curious and open mind.