An Interview with Ellenhorn’s Director of Pact Support, Miranda Levy

PACT Support at Ellenhorn

Ellenhorn, the most robust community-integration program in the United States, serves each client in their own home or community via the Program for Assertive Community Treatment (PACT) model of service. PACT, introduced in the 1970s, is now considered the evidence-based best practice for serving individuals with complex psychiatric needs—and rightly so. 

Our intensive multidisciplinary program, an effective and humane alternative to residential or hospital levels of care, is often referred to as a “hospital without walls.” Our individualized treatment approach combines psychosocial rehabilitation, medical/psychiatric care and a focus on physical wellness. From day one, we work toward each client’s reintegration into the community, reengagement with life and rediscovery of a sense of purpose and hope. We believe that psychiatric recovery and a person’s recovery of their sense of self and connection to others go hand in hand. 

That being said, we understand that the struggle with addictive habits and disruptive events of mind and mood does not end at 5 p.m., which is why Ellenhorn provides outreach services well into the evening and on weekends, and has clinical staff available 24 hours a day to respond in person to crises. The majority of our evening and weekend care is provided by our PACT Support team, who work in tandem with our clinical staff. Here to share some details of this provision is Ellenhorn Director of PACT Support, Miranda Levy.

 To start, can you tell us what you consider some of the best features of Ellenhorn’s PACT model?

“We are a multidisciplinary team, which means we take the best of traditional PACT work and add to it. By utilizing interventions like expressive-arts therapy, mentalization practices, occupational therapy, open dialogue and so much more, we are able to operate as a ‘hospital without walls.’ This means that we go directly to our clients in their homes and in the community, which allows everyone we work with to maintain their independence and remain connected to the world—all while receiving the highest standard of psychiatric care.” 

Tell us about PACT Support. 

“One of the things that makes the PACT model so effective, and one of the factors that makes it like a hospital without walls, is the fact that care continues after business hours. Here is where PACT Support comes in. We’re the members of the PACT team who continue the work of helping individuals to preserve their current lifestyle and sense of independence long after typical business hours. By providing support in the evenings and on weekends we allow our clients to retain their autonomy while working toward their clinical and social goals.”

What role does communication play in the PACT program and in assuring that each client’s care is seamless?

    “We recognize how important clear and effective communication is in providing meaningful clinical care—which is exactly why we designed PACT Support to be an extension of a client’s clinical team, rather than a separate entity. As such, communication is cohesive among all team members. PACT Support, like the rest of the PACT team, provides prompt updates and detailed clinical notes to assure that everyone is on the same page while we continue to work together toward each client’s goals. When it comes to PACT Support, communication is what allows us to provide seamless care.” 

Why do you consider PACT Support such a vital part of the PACT program? 

“Many individuals who are seeking psychiatric resources find the evenings and weekends particularly challenging. They can get lonely and feel unsettled without routine support. Our PACT Support team is passionate about mental health and able to bridge these gaps between clinical services by offering care outside the scope of regular hours. It’s so important that our clients do not feel isolated. When it comes to PACT Support, creativity is key. We work collaboratively with our clients to ensure that they feel supported no matter the situation. Whether that means going grocery shopping with them, helping them get to appointments on time, attending an activity together or simply sharing a conversation over a cup of coffee—we do it all. The most valuable parts of the PACT Support program are the meaningful relationships that are formed. I feel that these relationships play an integral role in instilling our clients with hope, and I consider it an honor to help bring PACT Support to Ellenhorn clients across the country.” 

You’re not the only expert in the room: Therapeutic Collaboration

At Ellenhorn, we place collaboration in therapeutic relationships front and center. In such a relationship, therapist and client work to achieve goals the client identifies as important, and that both agree they have the power to reach.  This is very different from a relationship in which the clinician, as an expert, figures out what is wrong with the client and prescribes a particular treatment protocol to fix it.

You can’t really talk about a collaborative therapeutic relationship without talking about a “treatment contract” that provides a sense of where client and clinician are going.  With that in mind, we call our plan the “Roadmap to Recovery,” and we’ve built this therapeutic contract to be collaborative.  The graphic below presents a picture of how we think about the Roadmap to Recovery.

Roadmap To Recovery

“If everything goes well here, what will your life look like six months from now?”  That’s the question we typically ask while building our Roadmap.  The answers form the “dream” at the top of the graphic.  Once we understand their dream, we work with clients to mobilize their strengths, and to remove as many barriers as we can, in order to achieve it.

That simple idea makes our Roadmap different from a typical treatment plan in which symptom reduction or behavioral change is the goal.  We work on symptoms and behavior with our clients, but only in pursuit of larger life-goals. Thus, the typical fodder for clinical interventions is not our central target.  The dream is our focus for our clients, the destination we share.  Most often, psychiatric issues emerge as barriers to reaching this destination, and together we work to remove these.

“Collaborative therapeutic relationship”: the words have a nice ring to them.  And they do point to humane and decent sentiments.  But collaboration is more than a nice value.  The collaborative relationship is scientifically proven to be the most effective kind of relationship in facilitating change.

This pie chart captures a surprising fact:  A hefty 30 percent of client change results from “common factors” in the relationship between client and therapist, that is, behaviors and attitudes exhibited by therapists, independent of the therapeutic approach they use, that promote change in clients.  As shown here, common factors are doubly powerful as change-drivers compared to specific therapy models.

Researchers have gone deeper into the question of what promotes change, examining which common factors are most important.  As the next chart shows, a collaborative approach is the winner (surrounded by its sister, alliance, and its cousins of empathy, genuineness and positive regard).

When we at ellenhorn are able to form a collaborative relationship with our clients, discussions with them that otherwise would place significant power in the hands of clinicians, take on an egalitarian hue.  No longer are we assuming that our formulations, diagnoses and prescriptions are the unquestionable guides for treatment.  Instead, we engage in a conversation with our clients in which we look at how psychiatric experiences, along with other factors that play a role in all our lives, may hamper our work to reach their dream.  This approach levels the playing field, giving the client significant voice. It doesn’t silent our opinions; rather, it gives us the ability to say what we think is happening without our opinion carrying more weight than theirs.

At ellenhorn, I’m allowed to have my own experience,” says one client.   “No one is trying to convince me, or pathologize my disagreements with them, saying ‘You’re in denial’ or ‘You won’t get well if you don’t see you are sick.’”

There’s a lot of room on the team for different voices,” she continues. “It’s a polyphony, rather than a unified front.  And I have a central voice in this polyphony. That’s a big relief for me, since I’m no longer judged as just a patient with no agency or input.  I can voice my doubts and express sadness, and have appropriate feelings about what’s happened, without feeling like someone is diagnosing me.

When this client gives an example of the times when she most felt the effects of our collaborative relationship, her answer points to an important and unique way we work:

“I’ve never had a group of friends who all saw me at the same time in my own environment and saw what was going on, and then approached me with that shared knowledge.  At ellenhorn, for the first time I have multiple people seeing and communicating with each other about how I am doing outside of therapy.  That’s the most important factor.  It’s really important that there are all these multiple views that can be checked with each other, and are windows into my world.”

This client felt the strength of our collaboration outside our offices, in her own home.  Her response captures another important factor in change: a person’s life outside therapy, or “extra-therapeutic events.” As the chart above indicates, they embody 40 percent of the factors that either produce or block change.

As the most robust community integration program in the U.S., we focus on these outside-the-office issues.  We do so collaboratively, combining the two most prominent supporters of change into one.  That means we put a lot of energy into issues other than a client’s purely psychiatric symptoms, working alongside our clients in the community to both deploy their strengths to reach their dreams, and remove barriers to these dreams.  “I was afraid of the visibility an outreach team would impose,” our client says. “But it turns out that it’s this very visibility that has made my time with ellenhorn so productive.   Allowing myself to be seen and known and even seen in different psychological states —  these things have to be seen literally by someone.  And having them seen in my own environment, without people judging me, makes feel like I don’t need to hide anymore.” 

Community integration programs, especially ones as comprehensive as ours, are often called “hospitals (or residential programs) without walls.” The concept of “without walls” sounds innovative, accessible, hospitable.  But walls don’t only keep people in; they also keep people out.  When mental health workers serve people in the community, they’re given access to their clients beyond the usual barriers of privacy the rest of us enjoy. When professionals walk through the doors of their clients’ homes to treat them, they wield significant power based on their ability to survey the most private parts of people’s lives.  But when we focus on having a collaborative relationship with our clients, that potentially coercive and monitoring spirit gets turned on its head.  Instead of entering a home from a position of power, we enter it with our eyes on where the client wants to go, and how we can help them get there.  Our client beautifully captures this union of collaboration and treatment in the community:

“Even though my entire history says I would find it threatening, I can now say that people coming into my apartment doesn’t feel threatening at all: it’s actually felt very freeing to have somebody come over and just check in and see what I’m doing. That would never happen in any other context.”

Announcing Ellenhorn’s First Annual New Perspectives on Treatment Series

Ellenhorn is pleased to announce a year-long series of talks investigating collaborative approaches to treatment, the science behind collaboration, the research on its effectiveness in therapy, and different means for building collaborative relationships with clients.


Decades of research on the common therapeutic factors leading to change repeatedly show that the most effective therapeutic relationships are collaborative ones. Too often, however, the notion of collaboration is approached by treaters as a starting point rather than as a destination. Many individuals who enter treatment, and especially those with complex issues, do so either because they suffer from a basic distrust of the world or out of compliance with the demands of others–scenarios that are poison to collaborative relationships. For these clients, the very idea that we start treatment with a partnership seems suspect, dangerous and bound to fail them. Try as we might to offer them the nutrients of a therapeutic alliance, they likely won’t metabolize what we offer.

Starting with the goal of a strong treatment alliance with our clients is easy; co-creating one with people who don’t trust us is hard work. When we call such individuals “treatment non-compliant,” “difficult to engage,” or “resistant,” we miss the point, seeing their reluctance to engage with us as purely a matter of their own flaws or issues, and not reflecting on our own misguided belief that our trustworthiness is a given.

Our series offers various breakfast and lunch-time presentations over the course of a year.  From a discussion of the science and research on collaborative relationships in therapy, to talks about Mentalization-Based Treatment, the Finnish model of Open Dialogue, expressive arts techniques and psychosocial approaches and therapies for substance misuse, we addresses the process of fostering therapeutic partnerships with individuals who are reluctant to enter into them.



Series Schedule


02/27: The Only Truth that Sticks: Distrust and the Complicated Path to Therapeutic Collaboration
Ross Ellenhorn, PHD
8:00 AM – 10:00 AM
Click here to register!

04/12: Recovery from Addictive Processes and Psychosocial Injuries through Therapeutic Collaboration
Zoi Andalcio, LMHC, CPT
12:00 PM – 2:00 PM
Click here to register!

06/12: Integrating Open Dialogue in PACT and Other Systems
Ross Ellenhorn, PhD
8:00 AM – 10:00 AM
Click here to register!

08/14: Mentalization for Teams: The Collaborative Nature of Curiosity
Carlene MacMillan, MD
12:00 PM – 2:00 PM
Click here to register!

10/16: Screen Signals: Healing through Social Media Influenced Projectives and Imagery
Anna Boyd, LCAT
8:00 AM – 10:00 AM
Click here to register!

12/12: The Social Psychological Ingredients for Collaboration: Self-Determination, Self Esteem, and Social Support
Ross Ellenhorn, PhD and Kent Harber, PhD
12:00 PM – 2:00 PM
Click here to register!



Can’t make it? Watch it online!

We will be broadcasting each talk online for those to watch who aren’t able to physically make it. However, please note that unfortunately we cannot offer CE credits for those who watch online.



Continuing Education


This event is co-sponsored by Ellenhorn, LLC and The Institute for Continuing Education. The program offers 2.00 contact hours with full attendance required. There is no additional charge to receive CE credit. Application forms and other required CE materials will be available on site. If you have questions regarding continuing education, the program, faculty, grievance issues, or for a listing of learning objectives, please contact The Institute at: 800-557-1950; e-mail:

To receive continuing education credit, participants must complete all CE forms, sign in/out at designated locations, and submit an evaluation of the sessions attended.

CE Credit: It is the responsibility of attendees to check with their state licensing/certification board to determine if CE credit offered by The Institute for Continuing Education will meet the regulations of their board.

Psychology: The Institute for Continuing Education is approved by the American Psychological Association (APA) to sponsor continuing education for psychologists. The Institute for Continuing Education maintains responsibility for this program and its content.

Counseling: The Institute for Continuing Education is recognized by the New York State Education Department’s State Board for Mental Health Practitioners as an approved provider of continuing education for licensed mental health counselors. Provider MHC-0016.
NOTE: NBCC credit is not offered.

Social Work: The Institute for Continuing Education, Provider 1007, is approved as a provider for social work continuing education by the Association of Social Work Boards ( ASWB ),, through the Approved Continuing Education ( ACE ) program. The Institute for Continuing Education maintains responsibility for the program. ASWB Approval Period: 04-13-2015 – 04-13-2018. Social workers should contact their regulatory board to determine course approval for continuing education credits.

New York: The Institute for Continuing Education is recognized by the New York State Education Department’s State Board for Social Work as an approved provider of continuing education for licensed social workers. Provider No. 0025.

New Jersey: This program has NOT been submitted to the NJ Board of Social Work for pre-approval.

Marriage-Family Therapy: The Institute for Continuing Education is recognized by the New York State Education Department’s State Board for Mental Health Practitioners as an approved provider of continuing education for Licensed Marriage and Family Therapists. Provider MFT-0012.

Skill Level: This program is appropriate for mental health professionals of all skill levels.
Instructional Methodology: May include didactic, lecture, audio visuals, demonstrations.