The director was a social worker trained in traditional office-based assessment and psychodynamic therapy. She soon decided that her training was simply irrelevant for serious mental illness, so she pushed her staff to newer types of interventions such as driving clients to appointments, helping them find housing, and negotiating on their behalf with employees, landlords, and roommates. At this early stage, no professional guidelines existed for the director to follow. She built her program through trial and error as she gradually discovered the best tactics to keep clients out of the hospital. Pragmatic innovation—in the absence of disciplinary knowledge or detailed instructions from above—created a new type of mental health service on the ground. Staff members followed individuals as they moved through their own spaces and rhythms of life, instead of demanding that they conform to the norms of office-based or hospital care.
CSP services after deinstitutionalization developed via a complex traffic between policy mandates, professional expertise and practical knowledge. At the start, federal policy makers established some broad conceptual outlines and a top-down plan for systemic reform. The scene then shifted to local programs around the country (such as High County, Kansas) where clinicians improvised ways to keep clients out of the hospital. Attracted by the programs’ evident success, established professionals in social work, psychology, and psychiatry scrutinized fledgling programs and scaled them up. Charles Rapp, a professor at the University of Kansas School of Social Welfare, accepted a contract to provide case management services at the High County agency. Rapp and his social work students evaluated his new approach (Rapp and Chamberlain 1985), replicated it in other agencies, and in 1983 articulated it in a training manual. He received a series of NIMH grants for further refinement and testing of what he now labeled “strengths-based” case management. His influence soon spread to higher levels in the public sector mental health system. In 1986, the Kansas Department of Mental Health contracted with him to provide technical assistance to programs throughout the state, and his research helped shape the Kansas Mental Health Reform Act of 1990 (Floersch 2002).
Rapp formalized the approach in his book The Strengths Model: Case Management with People Suffering from Severe and Persistent Mental Illness (Rapp 1998). The text lays out his core argument: individuals with severe mental illness can achieve a higher quality of life if enabling niches are available in their immediate environment. Opportunities for work, education, and social involvement strengthen people’s intrinsic abilities and facilitate their recovery, even if their symptoms remain. Rapp contrasts his “strengths” model to the “deficit” model typical of psychiatry, which he criticizes for focusing on pathology and increasing people’s dependency. Rapp develops his argument with a mix of human ecology, the psychology of resilience, and empirical studies of positive long-term outcomes for people with serious mental illness. His book features numerous flowcharts and lists of formal therapeutic principles that recast his pragmatic innovations into explicit and disciplinary correct form. He provides detailed instructions to set up a working program, including templates for key paperwork technologies such as assessment forms, treatment plans, and organizational charts that map the proper relations among agency director, middle management, supervisors, frontline workers, and clients.
Rapp’s textbook formalizes the conceptual rationale of a single experiment, standardizes the treatment model, and then supplies a blueprint for implanting it anew in different settings. The text thus exemplifies the transformation in CSP services from the 1970s to the 1990s. At the NIMH, a panel of experts developed an ideal vision of community services to redress the worst results of deinstitutionalization. Their mandate then diffused downward to the level of particular mental health agencies, where frontline workers translated ideals into workable programs on the ground. Individual clinicians used real-time, trial-and-error learning to figure out how to keep clients stable outside the hospital. In the third step, the results of their experimentation were scaled up, inserted into disciplinary discourses, and repackaged as manuals and templates generalizable to other settings. Over the following years, the standardized and transposable model for community services was legitimized by academic research, and it had broad effects in mental health policy and state law.
The same trajectory marks the history of Assertive Community Treatment (ACT), the most influential model for CSP-style services and the template for Eastside Services. The program dates from the earliest period of deinstitutionalization at Mendota Mental Health Institute in Madison, Wisconsin, a traditional state psychiatric hospital. In the 1960s, a small research team experimented with behaviorist techniques to produce neater personal appearance, better work habits, and more cooperative behavior among patients (Ludwig 1968). The goal was to prepare them for discharge and community residence, but to the researchers’ surprise, what people learned in the hospital did not generalize to success outside. Those who improved with in-patient treatments often ended up back at the hospital in a few weeks or months, disheveled and psychotic. By contrast, those discharged with substantial symptoms often managed quite well with community living.
In a set of recollections published on the website of the Assertive Community Treatment Association (the model’s national professional organization), Mary Ann Test—a professor of social work on the research team—describes how staff members’ frustration led to the birth of Assertive Community Treatment. During a ward meeting in April 1970, staff complained that their efforts were in vain, and they protested to Test and her psychiatrist colleague Arnold Marx:
“We don’t want to do another one of these programs where we try to get patients ready for life in the community. Even though they appear ‘ready’ when we discharge them, they come right back. What good are we doing?”
We directed the discussion toward what kinds of interventions might be more helpful to our patients. Eventually, one of the paraprofessionals commented, “You know, the patients that Barb Lontz works with intensively don’t come back. Maybe we should all go out and do what Barb does.” Barb Lontz was an innovative and spirited social worker on the ward that, among other things, helped clients with discharge planning. Indeed, when time allowed her, Barb did far more than plan discharge. She drove patients to their new residence in the community and then spent countless hours and days providing them “hands on” support and assistance to help them live in the community. Barb helped clients move in and get sheets on the bed and a telephone installed; she taught clients how to use the local Laundromat by doing laundry with them again and again. She instructed them to ride the bus to the mental health center to get medications by going side by side with them as many times as was needed. . . .
As we listed the clients with whom Barb had worked intensively and continuously in this fashion, it was indeed apparent that almost none of them had come back to the hospital! We talked about why these methods seemed to be effective and someone said, “You know, I think the community, not the hospital, is where our patients need the most help. . . . Other staff nodded in agreement and gradually voices got louder and suggestions more extreme. Finally, the room filled with excitement when a staff member proclaimed, “We ought to close down B-2. [the research ward at Mendota Mental Health Institute] and all go out into the community like Barb and help our clients out there, where they really need support and where it will do the most good!”
The meeting ended in a spirit of incredibly high morale. Rather remarkably, in a four-hour meeting we and our staff together had decided to change radically our own (and the existing) philosophy of care for persons with severe and persistent mental illness!4
It is an appealing origin story, whether or not every detail is correct. It omits, of course, the context of deinstitutionalization that drove similar efforts at community treatment across the country. Nonetheless, the story suggests that Assertive Community Treatment began with the pragmatic trial-and-error efforts of frontline clinicians, in the same manner as Rapp’s strengths model.5 The next phase of scaling up began almost immediately, given that the team at Mendota State all held faculty posts at the University of Wisconsin–Madison. They assembled a 12-month pilot program of community-based training in basic coping skills and compared it to a control group (of inpatients as well as patients discharged to usual aftercare