Alternative to PACT: Recovery at Your PACE

"Personal Assistance in Community Existence"

By Daniel Fisher and Laurie Ahern, NEC

Many of us in the consumer/survivor movement are critical of the combination of PACT (Program for Assertive Community Treatment) and Outpatient Commitment. PACT is an approach, which uses a team of professionals to provide continuous, ongoing treatment to consumers whom the system defines as needing high levels of supervision. Unfortunately, we do not have a simple, well-articulated description of the alternatives to these programs. We would get further in our arguments if we could easily and consistently describe a set of programs, which embody our values and principles. Indeed most of us would agree that when people are going through periods of severe emotional distress they need help in negotiating the multiple bureaucracies involved in maintaining an independent life in the community. I would suggest that we name our proposed approach PACE, Personal Assistance in Community Existence. As the acronym implies, we generally believe that each person sets their own pace for their recovery.

As the table below shows, there are central differences in the values and nature of the help provided through PACT and PACE. Perhaps the most fundamental difference between PACE and PACT is the way the programs deal with coercion. PACT programs rely heavily on coercion. They are rarely voluntary. People are assigned PACT teams based on the determination of the mental health system that they need such a team. In fact, the push for outpatient commitment is often coordinated with a push for PACT teams to carry it out. The most striking example was a case manager from Wisconsin. She informed me that 27 consumers she "covered" were under guardianship and that they only received their check after they received their Prolixin Decanoate shot( a major tranquilizer). PACE, on the other hand, would be a noncoercive program. It would be offered to people who seem in need of services but their participation would be their decision. PACE is based on the development of long-term, trusting relationships at the person’s own pace. Since recovery can often take a number of years, relationships are critical. Our research has shown that the most important elements in recovery are having someone to assist you who believes in you and understands you. Other research (Wellbeing Project, by Jean Campbell) has shown that 47% of consumers subjected to involuntary hospitalizations said they would never return to an outpatient clinic. We are sure that a similar feeling of mistrust and fear would be generated by an involuntary procedure such as outpatient commitment.

PACE is based on the view that mental illness is the result of a combination of severe emotional distress, insufficient supports, and an inability to cope which results in the loss of one’s social role. The goal is to assist people to completely recover through connecting them with supports so they can regain a role in society and leave their role as mental patient. In contrast, PACT is based on the medical model. This model is that people are inherently chemically imbalanced and always will be. The best the system can do is provide the medication necessary for maintenance. Complete recovery is not possible and the consumer will always need the PACT team. The nature of the helping relationship is quite different for these two approaches as a result of the differing philosophies. In the PACE approach, the primary helper would be a personal assistant similar to those offered to people with other disabilities by the Independent Living (IL) Centers. Just as with the IL movement, PACE would be based on consumer choice and consumer control of services. In that manner, people would be more motivated and would take greater responsibility for their own recovery. The type of persons who work as personal assistants is critical. In many cases, people who themselves have recovered, would make the best assistants because they have been there. They are people who are not afraid to develop a close relationship with the consumer and who believe in the consumer’s capacity to recover because they have done so themselves.

Another important difference between PACT and PACE is in the role of medical explanations. In most cases the medical model lies at the heart of PACT. The programs place a heavy emphasis on the role of medications. Great efforts are expended to ensure that their consumers are medication compliant. The philosophy of PACE, on the other hand, is that the problems, which bring on the label of mental illness, are complex interactions of mind/body/spirit which are unique to each individual. The problems need to be defined by the c/s/x themselves in the context of their sociocultural setting. The pathways to recovery are uniquely defined by each person for themselves and need to be holistic in scope.

Another difference in the approaches is in the role of natural supports. For PACE, developing positive connections between the c/s/x and their natural supports is a critical component because PACE is based on the philosophy that people can completely recover from mental illness. In PACT, natural supports play a peripheral role because it is understood that the person will always need PACT as their primary support.


Recovery at Your own PACE



A. Could anyone become mentally ill?


NO: labeled people not fully human


YES: therefore we are all equally human

B. Causality of Mental illness

permanent brain disorder causing illness

Severe emotional distress and loss of social role

C. Recovery

Life long process

Complete possible

D. Goal of help


Full recovery

E. Control

Coercion by team. Controlled by outside

Person centered,voluntary Control by self

F. Pace

Set by team

Set by consumer


A. Relationships

Professional distance

Peer connection

B. Main method


Person who believes in you

C. Setting

Into professionally-run

Into peer-run

D. Rights

Violated often


E. Outcome

Dependency, lacking responsibility

Self-management; gain sense of responsibility

F. Choice of help

Little choice: narrowly medical

Full choice: consumer-run, psychosocial, therapy

G. Primary person

Case Manager

Personal Assistant

H. Housing

Bundled to services through DMH’s

Unbundled, through housing authorities