The diffusion of ACT illustrates a key tension in community psychiatry: between the need for improvisation and practical knowledge, on the one hand, and the influence of formal models and regulation on the other. ACT began as an experimental response to the failures of deinstitutionalization. It was nurtured by psychiatrists and social workers with relatively elite academic standing. The treatment norms they devised were operationalized, published in manuals, and passed on to lower-status frontline workers. The model was implanted across the United States in settings with fewer resources and dramatically different social problems than a Midwestern college town. The ongoing implementation of ACT, of course, transforms daily practice despite attempts to ensure fidelity to the original principles, on the part of program evaluators and mental health policy makers. In the end, the infinite adaptations of the model and the top-down attempts to standardize and control clinical work place significant strains upon frontline staff.
Some of the adaptations took place at the organizational level. By 1995, several states had reformed their public mental health services in line with the ACT model (Deci et al. 1995). Local mental health administrators received consultation and training from the ACT founders, demonstrated cost savings, and persuaded state legislators and mental health departments to scale up services. Newly organized teams inevitably differed from the ideal model program. After all, they were not constructed de novo, but instead by retraining people already employed in the mental health system. To build up new teams, the ACT consultants enlisted outreach workers and alcohol counselors who actually knew very little about chronic psychiatric illness or the community support model. ACT planners took staff from the shrinking state hospitals or from traditional case management programs where clinicians had caseloads of up to 60 clients (instead of the ACT recommendation of 10). The earliest ACT teams easily drifted away from the original standards; clinicians continued to see the majority of clients in their offices during normal business hours or simply did not try to engage with people who refused contact. In response, ACT planners encouraged work teams to distance themselves from the daily operation of the surrounding agency. Teams started to have separate staff meetings and record-keeping systems, to develop their own network of housing options, and generally to develop their own organizational identity.11
The sheer expense of ACT also influenced how treatment ideals got translated into workable programs on the ground. Like so many community medical services established in the United States since World War II, ACT programs faced a crisis at the end of the demonstration period (cf. Starr 1982: 370). State mental health authorities turned immediately to Medicaid as the new source of funding, and their strategy had important long-term effects. First of all, Medicaid reimbursements cannot actually pay the entire cost of a full-fledged ACT program. Under Medicaid’s lower funding, a bottleneck appeared in the public mental health system, with doctors and social workers pleading for the few open spots. In 1992, therefore, step-down programs—less intensive, with fewer services and higher caseloads—were created for high-functioning clients. At the same time, administrators tightened admission criteria to reserve ACT slots for the most severely disabled and most often hospitalized people. The shift to Medicaid essentially retooled ACT programs to admit the most difficult clients and to encourage the healthier ones to leave sooner. Clinicians found their caseloads filling up with sicker and more disabled individuals.
Secondly, the ACT model fits poorly with the basic Medicaid categories for reimbursement, because it combines health and social services in a single delivery technology (Lewin Group 2000). For example, delivering in vivo treatment may involve several trips until a case manager finds her client, but most of this travel cannot be reimbursed. Teaching people how to shop or write a household budget falls entirely outside Medicaid’s definition of medical treatment. The recently implanted ACT teams came under pressure to tailor their services to the balky logic of Medicaid. This problem was solved in a way that profoundly influenced the conditions of work for frontline staff. ACT advocates made alliances with the highest level of state mental health authorities, and in the state where Eastside Services is located they managed to get program services inserted directly into state law. By working closely with the state mental health division, the advocates/planners ensured that community support programs are mandated in each county and spelled out in precise detail.
Eastside staff members, like all ACT teams in this state, must conform to the current administrative code: a triumph of bureaucratic control over everyday clinical work. The state code establishes the makeup of each local work group and the required training for each member. It establishes the maximum client–staff ratio and sets exact criteria for admission, including diagnosis and levels of impairment. The code dictates the order of work with newly admitted clients (assessment, treatment planning, services, record keeping, and discharge) and defines each phase of work in minute detail, enumerated by headings, subheadings, and sub-subheadings. The legalistic language reaches deeply into program operations and explicitly prescribes case managers’ tasks. It lays out the precise steps to help clients find a job (make wake-up calls, counsel them about grooming, and help them buy clothes). It delineates the specific living skills they must teach clients: housecleaning, cooking, shopping, laundry, and money management.
The daily activities of case managers, therefore, are governed by bureaucratic as well as clinical logic. Case managers operate with a split identity as both clinicians and public employees (cf. Friedson 2001). Even as they deal face-to-face with a client in her own living area, case managers must obey explicit definitions of their duties devised by a remote cadre of mental health administrators. Frontline staff never escape the control and surveillance of officials located higher up in the system.12 Case managers at Eastside Services often lack the prerogative to determine their tasks or how best to carry them out. They do not control the criteria by which their work is judged. To a remarkable degree among health care workers, their labor is specified in advance and in writing. The state code standardizes and rationalizes their tasks, and (on paper, at least) leaves them little room to resolve ambiguities and contingencies on their own.
Weaving ACT services into Medicaid financing demands especially tight surveillance of programs on the ground. To qualify for Medicaid, programs must meet the state certification standards. ACT planners support such audits because they provide a reliable measure of the fidelity of individual teams to the original principles.13 At Eastside Services, the state evaluator arrives every year to comb through clients’ charts and billing records. Pushed by this scrutiny from above, the supervisors in turn create structures of surveillance over the case managers. Supervisors continually revise and correct treatment plans, and in both staff meetings and face-to-face reviews they instruct and discipline the case managers in other details of paperwork (see Chapter Four). These types of surveillance immerse frontline clinicians more deeply in the bureaucratic mode of control.
Case managers must wrestle with yet another aspect of the micropolitics of work. Their structural weakness is produced by not only distant bureaucratic control but also their position vis-à-vis the psychiatrist on the team (see Test 1979). As a medico-social intervention, Assertive Community Treatment rests on an inherently complex division of labor. The program’s architects acknowledge the tension between case managers and higher status psychiatrists, who are accustomed to directing nonmedical staff members. To mitigate the friction, Stein and Santos (1998: 60ff) advise psychiatrists to be “helpful and collegial, rather than dictatorial and demeaning,” to teach case managers about medications and side effects, to accept calls after hours, and to come in occasionally on weekends. According to this ACT textbook, careful attention to social relationships will foster a well-functioning team despite the inevitable hierarchy.
At first glance, the psychiatrist on the team is indeed the topmost authority, with the highest credentials and surest control of the jargon and practices at the core of the ACT model. But the relationship between case managers and psychiatrists involves more than their rank order in the hierarchy. The two clinicians rely on different warrants for knowledge. The psychiatrist draws on in-hospital training with people in acute crisis,