The momentum continued as the researchers obtained NIMH funds to develop the Training in Community Living model, based on the same strategy of individualized supports provided in the community. The goal, however, had shifted because of the quickening pace of deinstitutionalization and the need for states to reduce the costs of inpatient care. The program now aimed at prevention of hospitalization instead of preparation for discharge. In 1972, the entire staff of a hospital ward was retrained and transferred to a rented house in Madison. Staff members met as a group twice a day to share information about clients and plan treatment. The rest of the time they visited clients at their homes, neighborhood gathering spots, or workplaces. Staff members consulted widely with family members and employers, and they provided clients with a full schedule of daily activities. They supplied medication, taught basic skills (shopping, cooking, grooming, budgeting, etc.), helped clients find housing and employment, and prodded them to get involved with recreational and social groups. The researchers evaluated the program and confirmed the earlier study: clients spent less time hospitalized and more time employed, and even showed symptom improvement. The program produced savings of $800 per patient per year, with no increased burden on family members (see Stein and Test 1980, Test and Stein 1980. Sue Estroff’s classic study [1981] describes this project from the clients’ point of view).6
These articles had an enormous influence on the emerging field of psychiatric rehabilitation. The authors described their program in commonsense terms that responded perfectly to the CSP vision (not surprisingly, since Leonard Stein and Mary Ann Test attended the original CSP conference at the National Institute of Health). To succeed in the community, people with serious mental illness need not only medical treatment but also material resources such as food, shelter, and clothing. They need to learn basic coping skills in real-world contexts. They need ongoing social support, and their families, landlords, and employers also need education about mental illness. The model program described by Stein and Test supplied precisely the range of services that people lost because of the phasing down of state mental hospitals.
Moreover, the authors’ methods and approach dovetailed with the contemporary neo-Kraepelinian revolution in American psychiatry as a whole: the renewed emphasis on the taxonomy of psychiatric disorders and the search for organic causes. The articles were published in 1980, the same year as the DSM-III, the Diagnostic and Statistical Manual of Mental Disorders (3rd edition). During late 1970s, American psychiatry began to move toward explicit, research-tested, discrete criteria for disorder—the template for medical psychiatry laid down by Emil Kraepelin almost a century before. The DSM-III aimed to rationalize psychiatric research as a scientific enterprise by providing stable and mutually exclusive categories for disease. With these stable categories in hand, all researchers could be confident they meant the same thing by schizophrenia or depression. The Madison group applied the same logic to mental health services. They measured outcomes in a way that invited further refinement and testing, with validated and reliable instruments that quantified community adjustment, self-esteem, family burden, and so forth. With these outcome measures in hand, researchers across the country could replicate the program and test it against other modes of treatment. Assertive Community Treatment (ACT) eventually became the most thoroughly studied intervention in American community mental health services.7
In 1998, after almost 30 years of development, several long-time ACT clinicians published comprehensive manuals that provide a conceptual rationale and detailed instructions for running programs (Stein and Santos 1998, Allness and Knoedler 2003 [1998])8. Taken together, the books fulfill the same functions as Rapp’s text, but from a different angle. Whereas Rapp criticizes the medical focus on deficits, Leonard Stein and Alberto Santos are both psychiatrists, and they explicitly frame mental illness as a chronic disease parallel to diabetes, hypertension, or arthritis. They present the orthodox medical view of chronic conditions as alternating between acute episodes and periods of stability accompanied by long-term impairments. The out-of-control and the stable phase each requires distinctive treatments. For certain serious mental illnesses (the authors single out schizophrenia and schizoaffective and bipolar disorders), the acute phase involves psychosis and disorganized or bizarre behavior. Hospitalization and medication are the appropriate treatment. The stable phase involves several key impairments: vulnerability to stress, deficient life skills, difficult interpersonal relationships, and inability to generalize skills learned in one setting (such as the hospital) to another (the community). Stein and Santos devised ACT to target precisely these impairments via continuous support and the teaching of life skills in the immediate contexts of patients’ lives. ACT also delivers pharmaceutic treatment directly to people’s homes in order to prevent relapse.
Stein and Santos endorse the now dominant paradigm of contemporary American psychiatry. Mental illnesses are brain diseases: discrete, organic malfunctions, each with its characteristic signs, symptoms, course, disabilities, and appropriate medications (see Luhrmann 2000 and Lakoff 2005). They write their ACT handbook as clinicians first and foremost, not critics of deinstitutionalization. The revolving door pattern is simply bad medical practice that treats the acute episode but neglects the stable phase of a chronic but manageable disease. Treatment during the remission phase is critical because what happens between episodes affects the severity and frequency of relapse. This rationale anchors their entire vision of Assertive Community Treatment. To help clients with community living, ACT teams must be multidisciplinary, comprising social workers, nurses, psychologists, psychiatrists, vocational specialists, and experts in drug and alcohol treatment. To prevent relapse and hospitalization, they must be ready to intervene around the clock, seven days a week. They must take ultimate responsibility for providing what clients need, when and where they need it, and not force them into 9-to-5 schedules and office appointments. In practice, this means that ACT staff members themselves deliver as many services as possible. When forced to broker services with outsiders, they must monitor and coordinate the relevant agencies. The 10-person ACT team is the fixed point of responsibility that ensures clients receive all necessary services from the fragmented nonsystem of public mental health.
The instructions for everyday work and the organization of ACT teams embody the biopsychiatric view of severe mental illness. Because predictors of relapse are subtle and unique to each person, clinicians must continually scrutinize clients’ lives to discern the symptoms, stressors or lifestyle changes that precede psychotic breaks or disorganization. Because the needs of clients can change quickly, everyone on the team must know every client: case managers share details of their own caseload with the entire group during morning staff meetings. Because of their poor transfer of learning among people with severe mental illness, clinicians must deliver services in the real contexts of clients’ lives: shelters, meal sites, clients’ apartments, and workplaces. Borrowing a metaphor from laboratory science, the ACT literature champions in vivo as opposed to in vitro services. Because of clients’ disorganization, anxiety, and poor coping skills, clinicians must act assertively to help clients benefit from treatment. If a client does not answer the phone, staff members drive out to his apartment. If he is not at home, they comb the neighborhood to find him. Clinicians continue to seek out clients even if they refuse contact for months on end. Finally, this model assumes that serious mental illness is chronic disease with lifelong impairments. Allness and Knoedler (2003: 397) provide sample discharge criteria, but they warn that clients should not be discharged for “traditional reasons” like needing less care or because their problems are too complex.
Assertive Community Treatment is the single most well-known model of mental health services that appeared after deinstitutionalization. A cadre of researchers continues to refine the approach, apply it to new populations, identify its core ingredients, and measure whether ACT teams on the ground adhere to the model’s standards.9 Even as a pilot program, it won the Gold Achievement Award from the American Psychiatric Association in 1974 (Dixon 2000). In 1996, the National Alliance on Mental Illness—the leading mental health lobby in the United States—officially endorsed ACT and began to pressure federal and local officials to make it available nationwide (Allness and Knoedler 2003: xi). In a coordinated effort, the federal Substance Abuse