C onsumers The Alaska "Mental Health System" has decided that it is going to downsize API to 54 beds, which is fewer patients than it has virtually ever had since it opened in 1962.  The idea is that instead of hospitalizations, people should be treated in the community whenever possible.  This is, of course, something everyone wants.  The original plan to go along with the downsizing was: (1) a Single Point of Entry (SEP) that would evaluate all entrants into the emergency mental health services system and determine the most appropriate place for the person, and (2) a local hospital operating a Designation Evaluation and Treatment (DET) facility to handle people who need short term evaluation and stabilization.  Neither of these services were achieved as a result of a bid solicitation process.

In order to overcome this difficulty, the State proposed that a PACT team be created in Anchorage.  Consumers around the country are very opposed to PACT Programs as they have been extremely coercive in many cases.  See,

Academic research is also  beginning to agree with this position.  See:

H aving
O wnership
I n
C reating
E ffective
S ervices

Consumers are saying that the biggest problems with the mental health system are (1) the coercive nature of the "treatment" and (2) the lack of choice.  Therefore a consumer-driven, choice oriented approach to achieving inpatient-reducing community services that looks something like the following is being proposed:

  1. The CHOICES program would have at least a 51% consumer board of directors and a professional advisory board and professional staff and contractors available as well as peer support.  
  2. The CHOICES program would be Medicaid eligible and bill as such, but efforts would not be focused on fitting clients into Medicaid billing categories.
  3. Patients being discharged from API would be given the choice of (1) a "traditional" discharge plan or (2) "joining" the CHOICES program.  CHOICES program representatives would consult with patients prior to discharge to describe the CHOICES program to the patient. Advanced Directives where the client pre-determines the conditions for determining a relapse and the treatments to be administered in such event would be a feature at this phase.
  4. The fundamental approach is to try and move people to recovery as opposed to symptom management.  The universal experience of people who have recovered from serious mental illness is:

    1.  You have to take responsibility for your own mental health and behavior.
    2.  You have to learn to recognize your symptoms.
    3.  You have to learn what works for you.

    See, Recovery From Mental Illness.  In order to accomplish this, you really do need to let consumers try what they think will work.  Otherwise, we can not learn what does and does not work for that individual.  What works may be wildly different for different people so just because it has worked for Sally and many others doesn't mean it will work for Bill.  And it almost certainly won't work for Bill if it is forced on him.

  5. Accordingly, the services delivered would be determined on the basis of the clients' wishes.  The client would choose such things as his or her psychiatrist, therapist and case manager.  If the client says that the most beneficial thing to keep him or her from having a relapse is a good place to live, even if it is not a "normal"  living situation, then that becomes the most important thing to the program.  If the client knows a private psychiatrist or therapist or some other helper that he or she believes would be particularly helpful to him or her, that professional will be utilized, if at all possible.  If the client thinks that violin  lessons will be beneficial, then that would be tried.  Sometimes the choices will work and sometimes they won't, but they can always be part of the journey to recovery.

It turns out that an experimental program for homeless people suffering from mental illness in Florida, also called "Choices" has yielded interesting results.  See, Addressing Self-Defined Goals Improves Psychiatric Status of Homeless People.

"The thought of giving clients more control is something program staff really struggled with. " Dr. Shern said. "The magic is, you find when you really do that, the things they want are not that unreasonable, that they can make choices for themselves and their choices have consequences, and you talk through that with them. You start to develop a relationship because you've become allies." 

The original PACT Discussion Draft Proposal calls for an approximately $1.8 million annual budget, which all goes to and in support of (e.g., rent, mileage, etc.) the 12 full time position team members.  We propose instead a system built around independent case management.  Thus, $500,000 of the $1.8 million would be used on and in support of the independent case management, in which a high percentage would be for peer specialists.  The other $1.3 million would be used to purchase independent services for 130 people to be in the program. To do this, $10,000 would be available to each person in the program to purchase psychiatric, psychotherapy, vocational training or other other services, or to meet physical needs such as the security deposit on an apartment, eyeglasses, dishes, etc.  The CHOICES Program would have an arrangement with its own psychiatrist and services could be made available from that psychiatrist, but people in the program would be free to choose a different psychiatrist.

Last modified 12/2/2000