On July 21, 2010, Art Walaszek wrote to John Battaglia:

Just a heads up … I’m going to have a preliminary discussion with the Associate Dean on Friday regarding University of Wisconsin Hospital and Clinics funding a PACT rotation. My initial proposal will be to fund one PGY4 resident for one day per week for a year (0.2 FTE). This would be part of a broader Community Psychiatry track within the PGY4 year.

Dr. Battaglia and Dr. Walaszek had formed a friendship while working together over several years on an inpatient psychiatry unit affiliated with the University of Wisconsin School of Medicine and Public Health (UW). Dr. Battaglia later left UW to become the psychiatrist at the Program of Assertive Community Treatment (PACT) in Madison, Wisconsin, and although PACT had no formal relationship with UW, he remained on as Adjunct Clinical Associate Professor of Psychiatry.

PACT is where it all began…the world’s first psychiatric assertive community treatment. Sometimes referred to as “the Madison Model,” PACT won the prestigious American Psychiatric Association 1974 Gold Achievement Award for innovation and excellence in community mental health [1]. PACT services include direct assistance with self-care skills, activities of daily living, housing, physical health care needs, vocational rehabilitation, educational rehabilitation, social skills training, AODA counseling, family counseling, supportive psychotherapy, cognitive behavioral therapy, medication monitoring, and intensive psychiatric treatment. In 1998 the National Alliance on Mental Illness (NAMI) recognized 25 years of the documented treatment success of the PACT model in serving people with severe mental illness and announced an initiative to bring the PACT treatment model to every state by 2002 [2]. At this time, PACT remains the gold standard for team-based, case management in the community for those suffering from chronic and severe mental illness.

Over four decades of existence, PACT has been a training site for assertive community treatment programs both within and outside the US. PACT has been a popular training site for social work interns, psychology interns, nursing students (including nurse practitioners), and occupational therapy students. Despite this rich heritage in community psychiatry training, PACT had not served as an educational resource for medical students or psychiatry residents at UW.

After Dr. Battaglia moved to PACT, Dr. Walaszek became the UW Psychiatry Residency Training Director. Claudia Reardon, M.D., was a resident in the training program under Dr. Walaszek’s directorship. While a resident, she also met Dr. Battaglia, who, as an adjunct faculty member, served as her individual weekly supervisor and also presented seminars to her residency class. Through their continued professional and personal relationships, Drs. Battaglia, Walaszek, and Reardon realized the tremendous educational resource of PACT for students and residents at UW. Dr. Walaszek’s message to Dr. Battaglia was the signal that, after years of discussion, a UW-PACT collaboration might finally happen.

In my opinion, I am the luckiest psychiatrist in the world. In 2005 I was hired to be the psychiatrist for PACT in Madison, the Tigris and Euphrates Valley of assertive community treatment. This position was held formally for the most part by only one psychiatrist since the program began in the 1970s. It is, simply put, my dream job. I get to utilize all my skills and training in psychotherapy, crisis intervention, emergency psychiatry, psychopharmacology, and internal medicine for patients with severe and chronic mental illness, all of whom have failed to respond to the regular array of mental health services. I’m constantly stretching my psychopharmacology skills by utilizing novel, off label, and controversial treatments, because most PACT patients are treatment resistant to standard medication regimens. I’m the PACT team leader and I’m mobile, seeing patients wherever they need to be seen, whether at the PACT office, at their apartments, in group homes, at shelters, in the jail, or on the streets. This treatment mobility, while taxing at times, lends an essence of adventure and excitement to my work. With my PACT patients I have gone to picnics, been to the movies, celebrated holidays, attended high school graduations, and have also attended a wedding (of a PACT patient). Talk about being a multidimensional healer in all the best ways—I’m very involved in the lives of the most disadvantaged people on earth…and…I’m able to make a difference. Because of this high level of involvement, being a PACT psychiatrist involves a different level of responsibility for the PACT patients, a sense of “ownership” for the quality of their lives. PACT works, and I’m excited to be a part of it.

Since leaving full-time work at the UW in 2004, I’ve continued in my role as Adjunct Clinical Associate Professor through teaching seminars in community psychiatry and supportive psychotherapy and supervising residents. Always in the back of my mind was how to bring the educational gold mine of PACT to psychiatric trainees. Since it was established, PACT has been a substantial training program for students of all types as well as for mental health professionals from within and outside the US. The country of South Korea is currently embarking on a nationwide effort to incorporate the PACT model in all of its outpatient mental health clinics and has sent delegations of psychiatrists, nurses, social workers, and administrators to Madison PACT over the past decade for training. On a daily basis PACT staff are providing training for multiple levels of mental health trainees and professionals locally, regionally, and nationally. We live and breathe the PACT model and help others to do the same. The PACT esprit de corps is robust. There had to be a way to get this to UW psychiatric trainees.

In 2004, I was given a tremendous opportunity: to lead the UW Psychiatry Residency as it moved into a new world of Accreditation Council for Graduate Medical Education (ACGME) competencies and duty hours. Our residency’s vision is “Psychiatry residents at the University of Wisconsin will compassionately and effectively care for the mental health of individuals and of the community, and will contribute to the field of medicine and to society through scholarship and service.” This is a program with a rich tradition of community psychiatry training, with leaders in the field such as Len Stein and Ron Diamond involved in educating our residents for many years, and with clinical rotations at the Mental Health Center of Dane County (now Journey Mental Health Center). We also subscribe to the Wisconsin Idea, “the principle that the university should improve people’s lives beyond the classroom … [through] teaching, research, outreach and public service” [3]. Thus, a critical goal for me has been to ensure that our residents have excellent training in community psychiatry. At the same time, I wanted to ensure that our residents were graduating truly prepared to practice twenty-first-century psychiatry, including being skilled at delivering evidence-based pharmacotherapy and psychotherapy; incorporating neuroscience into clinical practice; understanding the mental health system, and the role of psychiatrists in effecting change in that system; advocating for patients, including working with legislators and policy makers; providing care for an increasingly diverse population of patients; using the principles of quality improvement to continually enhance the care we provide; and working with our colleagues in primary care to deliver mental health care to large populations.

So, we faced a challenge: how do we expose residents to traditional community psychiatry models such as practiced at PACT (where our residents had not yet rotated) while simultaneously preparing them for new models of practice? We faced another challenge: how do we fund such educational experiences at a time of shrinking resources? My early discussions with Dr. Battaglia about a resident rotation at PACT had been hypothetical because I could not figure out a way to fund such a rotation. Though grant funding might have been available, it would not have resulted in sustained funding.

An opportunity emerged in 2010. Six years into my role as residency training director, I had forged good relationships with the graduate medical education leadership at UW and had helped demonstrate the value of the residency to the institution. I argued that in order to continue to recruit outstanding residents to Madison, we had to demonstrate what was unique about us—and one way Madison distinguishes itself is by being the home of the agency that developed the ACT model. Offering a UW-funded rotation at PACT would help draw residents to Madison and would also help UW provide service to the community. Our Associate Dean (who oversees graduate medical education) agreed, and the UW Psychiatry Residency Community Psychiatry Track was born.

In 2002, about 2 years before Dr. Battaglia would become the PACT psychiatrist and Dr. Walaszek would become the psychiatry residency training director, I (Claudia Reardon) was a first-year medical student at UW and started volunteering for a free psychiatry clinic housed in a shelter for homeless, seriously mentally ill people in Madison. I quickly came to love community psychiatry. Of all the patients with whom I interacted during medical school, those mentally ill patients in community settings inspired the most empathy in me, and they also seemed incredibly grateful for any care we were able to offer, even when it did not seem like much. At that time, I aspired to be a community psychiatrist.

During the next step on my educational journey, psychiatry residency at UW under Dr. Walaszek’s leadership, I came to love what some would view as quite the opposite setting: academia. When the opportunity to take a UW faculty position as Associate Residency Program Director arose, I could not turn it down, because teaching and especially mentoring are among my favorite professional activities. With my appreciation for community psychiatry ongoing, it was important to me that residents in our program would be given opportunities to participate in “the Madison model” of care. It would be truly unfortunate if the psychiatry residency program in Madison could not offer training in this model! As a resident, I had traveled to the PACT building for my weekly supervision with Dr. Battaglia, and the atmosphere there always seemed so collegial and relaxed (some mental health providers even wore shorts during the summer—not something I was accustomed to seeing in the academic world). I have pleasant memories of sitting in the PACT waiting room alongside PACT clients as we exchanged conversational pleasantries, waiting for Dr. Battaglia to start our supervisory hour. Often such conversations were steeped in delusional thinking on the part of the clients, but regardless, they appeared to feel safe and cared for in the PACT environment. I wanted our residents to have the unique opportunity to rotate in the PACT setting, but unfortunately, challenges related to funding of community-based rotations for residents were increasing.