services of indefinite duration, including living arrangements and daytime and evening activities6 Medical and mental health care
7 Backup support to families, friends, and community members
8 Involvement of community members in planning services
9 Protection of client rights through grievance procedures
10 Case management: a single person or team responsible for remaining in touch with clients on a continuing basis.
With this list, the architects of the Community Support Program made a clean break from previous decades of policy. They did not even mention prevention or cure, but focused instead on rehabilitation and ongoing support. Their list thereby acknowledged people’s broad needs for simple survival in the post-asylum era. Often poor, unemployed, and marginalized, this group faced not only the fragmented mental health system but also the dispersal (or nonexistence) of all the other services that once came bundled together in the state hospital. Planners also endorsed the notion that severe mental illness is truly chronic and that some people may need comprehensive assistance for life.
The Community Support Program was the first comprehensive plan to reorganize services after deinstitutionalization. As a distinct program, it was cut short by the fiscal austerity of President Ronald Reagan, which effectively ended the era of national mental health planning that Kennedy began almost 20 years before. The program’s basic orientation, however, continued to drive the development of services at the state and local level, despite the ideology of limited government and the ongoing privatization of health care. In the 1980s, states devised programs that mixed and matched ingredients from the original CSP list of 10 essential functions. Vermont, for example, established regional “community rehabilitation and treatment” agencies that provided vocational training, social support, case management, emergency care, and education for family members (Wilson 1989). Columbus, Ohio, established “community treatment teams” that kept up with clients through all their moves about the city, brokered for services from different agencies, and placed clients in supported housing (Fleming and York 1989).
THE INVENTION AND DIFFUSION OF MODEL PROGRAMS
Building up the apparatus of community-based treatment demanded an enormous amount of improvisation. The problems left in the wake of deinstitutionalization overflowed the bounds of any single mental health specialty (psychiatry, psychology, social work, or nursing). To reconstruct a decent support system for people living in poverty and isolation required gathering resources from different institutions and experimenting with new organizational logics. This open-ended moment of invention, however, soon gave way to an era of precise blueprints and bureaucratic regulation. As new models of treatment were scaled up and woven into state mental health codes, the frontline provider had considerably less room to maneuver. His tasks became spelled out in minute detail, routinized, and audited from above. This tension between the need for improvisation in community services and the strict definition and regulation of clinical roles still pervades daily work in agencies like Eastside Services.
The development of services on the ground demanded the translation of CSP rhetoric into recipes for action with clients. The task often fell to social workers, who by necessity relied on their pragmatic and highly local knowledge to organize programs. The development of Community Support Services in the pseudonymous High County, Kansas, illustrates the translation from policy ideals to the operation of a single local agency (Floersch 2002). In the mid-1970s, administrators of an already existing mental health center looked to revamp their services for recently discharged patients. They linked up with the Community Support and Rehabilitation branch of NIMH, and a full-time director arrived in 1982 to turn rehabilitation principles into a workable operation.
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
