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 services). After five months, the experimental group had spent less time in the hospital and had better living and employment situations (although with no change in symptom level) (Marx 1973). Published evidence, following the disciplinary norm of randomized controlled clinical trials, had legitimized the intuition of social workers in the field.
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
