Applied Research and Evaluation in Community Mental Health Services: An Update of Key Research Domains 9780773586567

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applied research and evaluation in community mental health services

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Applied Research and Evaluation in Community Mental Health Services An Update of Key Research Domains Edited by evelyn r. vingilis and stephen a. state

McGill-Queen’s University Press Montreal & Kingston • London • Ithaca

© McGill-Queen’s University Press 2011 isbn 978-0-7735-3795-8 Legal deposit first quarter 2011 Bibliothèque nationale du Québec Printed in Canada on acid-free paper that is 100% ancient forest free (100% post-consumer recycled), processed chlorine free This book has been published with the help of a grant from the Canadian Institute of Health Research. McGill-Queen’s University Press acknowledges the support of the Canada Council for the Arts for our publishing program. We also acknowledge the financial support of the Government of Canada through the Book Fund for our publishing activities.

Library and Archives Canada Cataloguing in Publication Applied research and evaluation in community mental health services: an update of key research domains / edited by Evelyn R. Vingilis and Stephen A. State. Includes bibliographical references and index. isbn 978-0-7735-3795-8 1. Community mental health services. I. Vingilis, Evelyn II. State, Stephen A., 1949– ra790.a67 2011

362.2'0425

c2010-905846-1

This book was typeset by Interscript in 10.5/13 Sabon.

To my parents, Evelyn and Jerome Vingilis, who shared their love of the arts and sciences, and to my daughter, Larissa, who gave me a reason for sharing it evelyn vingilis

To Hannah and Robin in memory of Barbara Janet Novak stephen state

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Contents

Acknowledgments

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1 Introduction 3 evelyn r. vingilis and stephen a. state 2 Community-Based Treatment: A New Idea a Hundred Years and More in the Making stephen a. state

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3 Issues and Challenges in Community Mental Health Services: Program and Policy Evaluation 33 evelyn r. vingilis 4 Interfacing Hospital and Community Mental Health Services: The Role of the Emergency Department 55 beth mitchell 5 Research on Community Treatment Orders richard o’reilly

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6 The Criminalization of Mental Illness 80 virginia aldigé hiday and heathcote w. wales 7 Perspectives on Violence Risk Assessment and Management in Mental Health Services 94 anne crocker, gilles côté, and erika braithwaite 8 The Social Stigma of Mental Illness ross norman

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9 Consumer Participation in Mental Health Services geoffrey nelson and jill grant

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10 Housing and Mental Health 146 cheryl forchuk 11 Collaborative Mental Health Care: The Evolving Narrative in Primary Care 160 raj velamoor and stephen a. state 12 Current Developments in Assertive Community Treatment 182 joan bishop, lindsey george, steve lurie, and robert wales 13 Supported Employment eric latimer Contributors 233 Bibliography 239 Index 347

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Acknowledgments

This collection was made possible by support from the Canadian Institutes of Health Research through an Inter-disciplinary Capacity Enhancement Team grant, 2003–9. That support enabled and empowered the expansion of the Consortium for Applied Research and Evaluation in Mental Health (caremh), centred at The University of Western Ontario. Evelyn Vingilis was the principal investigator on the grant and the director of caremh. Stephen State was the coordinator of the caremh program.

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applied research and evaluation in community mental health services

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1 Introduction Evelyn R. Vingilis and Stephen A. State If people would go and … take them for a ride on Sunday, take them out for Sunday dinner sometimes, do some of these things. Ontario minister of health, speaking in 1970 about what was needed to make de-institutionalization work (Simmons 1990, 166)

Mental illness is a profoundly challenging disease, challenging first of all to those who suffer with it, since in many cases the symptoms of the illness will impair family and social relationships, as well as economic well-being. Instead of receiving sympathy, those who suffer with mental illness are more likely to experience stigma and isolation. And there is less likely to be appropriate treatment for them than for those who suffer from other diseases. According to a 2008 study, in high-income countries 23.7 percent of persons with a mental illness received treatment, compared to almost 65 percent of persons with a physical disorder; in low- and middle-income countries the percentages for the treatment of mental and physical ailments were 7.7 and 53.2 respectively (Ormel et al. 2008). The prevalence of mental illness is also disturbingly high: the estimated lifetime likelihood of an individual having at least one disorder ranges from 47.4 percent in the United States to 12 percent in Nigeria; across the world, the approximate projected lifetime risk of any disorder ranges from 20 percent to 50 percent (Kessler et al. 2007). The accompanying burden of this disease is considerable (Wittchen and Jacobi 2005; Vos et al. 2001; Mathers et al. 2001; Kessler et al. 2008). To give but one example, in Canada in 2004 the estimated costs for the single mental illness of schizophrenia, costs that included inputs related to healthcare, along with other inputs

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Evelyn R. Vingilis and Stephen A. State

not related to healthcare and higher unemployment and productivity losses, amounted to Can$6.85 billion (Goeree et al. 2005). This figure leaves out the less easily monetized costs of caregiver stress, family and social dysfunction, and impairment in role functioning (Druss et al. 2009). Fifty years ago, the principal venue for the care and treatment of persons with serious mental illness in virtually every jurisdiction of the developed world was the large and remote psychiatric hospital – an institution that was part haven and part prison. For various complex reasons, discussed in the historical background piece in chapter 2 by Stephen State, it no longer is. However, the lengthy movement to reposition the care of persons with serious illness in “the community” began more as a dream than as a plan. It was not at all clear what would happen when the large hospitals dramatically reduced their in-patient populations, it was not clear what services or treatments would best accommodate persons with mental illness living in the community, and, obviously, it was not possible to undertake research on the services and community interventions that might be devised in order to address problems that had not yet materialized. The practice of community treatment in virtually every jurisdiction encountered considerable initial difficulty and remains a work in progress, interwoven in its trajectory with profound changes in healthcare administration, funding, and treatment modalities. The “community” is, of course, a venue not an intervention, and it has taken some time for helpful services, let alone evidence-based practices, to emerge. In 1960, for example, the Community Mental Health Journal (CMHJ ) was still five years away from its first issue. The Canadian Journal of Community Mental Health would not begin until 1982. A research update in the opening 1965 issue of CMHJ by Anita Bahn (1965) acknowledged the cutting-edge introduction of epidemiological data collection and psychiatric case registries in Maryland in order to ascertain just what was going on. No one really knew. There was little in the way of programs or policies to talk about. The nation-wide US planning for the new community mental health program – a policy shift “based on theory and hope rather than fact”(Grob 1992, 20) – was still at the stage of collating analyses of what was out there. In the event, it would begin by focusing more on the moderately mentally ill, not the more seriously ill. In Canada, as in other jurisdictions, there were no assertive community treatment teams; there were no employment support programs, no

Introduction

5

diversion programs, no mental health courts, no mobile crisis teams. There was no consumer involvement in treatment plans or program development and, beyond ill-equipped nursing homes, almost no appropriate supported housing for persons with serious mental illness living in the community. However, more effective programs and services for the care and treatment of persons with mental illness are now in place in many jurisdictions around the world, owing in no small measure to applied research and the evaluation of interventions in natural environments (Lehman 1998). The challenges of research in community mental health services are as considerable as the research is important. Community mental health treatment necessarily occurs with regard to some variously specified client population of a particular age, gender, diagnosis, class, and awareness; and within a set of contingent and fluid cultural understandings that are embedded in often-changing policy and governance contexts. Since it is brought about through a wide range of service providers and under the uncertain direction of unpredictable political forces, fiscal constraints, and funding designs, there is much to control for. Despite these challenges, community mental health services have now matured into a more or less well-defined field, the several parts of which were in most cases unanticipated in the early days of de-institutionalization. Despite the many challenges, it might also be said that community mental health services research has come of age. The field has grown; it is now differentiated in a way that reflects the many discrete dimensions of mental health care in the community. The research that supports this field has also grown. The point of our collection is to provide an overview and update of current research in specific sub-fields of community mental health services. Our collection does not claim to be comprehensive. Many areas that could have been included have not been – inter-professional training and education, crisis intervention programs, consultation liaison psychiatry, mental health in the workplace, and psychosocial rehabilitation, to mention a few. Their absence provides an argument for the publication of future volumes. As well, important aspects of mental health services are not so much research areas as they are guiding approaches or models for the delivery of care. An example would be the emerging recovery movement (Roe et al. 2007; Onken et al. 2007; Corrigan et al. 2007; Deegan 2007), which is moving from a stage of conceptual clarification to develop more precise research questions.1

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Another example would be the distinction between bio-medical and psycho-social approaches, the former focusing on treating the illness; the latter on supporting and empowering the person. We take no stand on that ideological divide – if there is one; our assumption is simply that well-designed research can assist in answering useful questions. Each of us as contributors to this collection may well hold views – even strong views – regarding those important questions of principle. However, the unifying spirit that more properly characterizes our endeavour is closer to what John Locke (1975, 10) has called the “underlabourer” approach to the advancement of knowledge. It is a modest approach undertaken in a spirit of pragmatic investigation, advancing by careful examination of evidential claims. This admittedly pedestrian enterprise draws shamelessly on the many efforts of all those researchers whose work we have explored. We are also united in a set of related hopes. We want to know what interventions, policies, and programs for persons with mental illness living in our communities hold up to evaluation; we want to know what works. We want to assess, carefully, the claims of those whose pilot studies or demonstrations might offer models to be copied; we also want to avoid the bandwagons around novel interventions whose results may not in the end justify early enthusiasm. Many of the contributors to this collection are members of the Consortium for Applied Research and Evaluation in Mental Health (CAREMH), which was funded for five years (2003–8) by a Canadian Institutes of Health Research Interdisciplinary Capacity Enhancement Team grant. CAREMH membership includes individuals from the disciplines of business, correctional services, economics, education, epidemiology, family medicine, law, nursing, political science, criminology, psychiatry, psychology, social work, and sociology. These individuals are researchers, health care practitioners, policy analysts, administrators, and managers working in district health councils, acute care and psychiatric hospitals, private practice, social services, housing, and police and correctional services. In addition, consumers and their families have contributed as key members in numerous capacities, for example as researchers, health care practitioners, policy analysts, administrators, and managers. Many of the contributors are Canadian, and although some of the fine-grained particularity emerges from the Canadian context, the focus necessarily includes research undertaken in the United States, the United Kingdom, Europe, and Australia and New Zealand.

Introduction

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The worlds of researchers and potential knowledge users are social systems defined and identified by their own sets of rules, values, languages, and communication patterns. Knowledge gaps occur when there is a lack of shared knowledge, values, common perceptions, and inter-system communication patterns. Models of knowledge translation and utilization imply that the gap can be bridged if persons, groups, or resources are interposed between the two systems. This book attempts to bridge the gap by providing a synthesis and overview of key research findings, best practices, and future directions for research and practice on topical and important issues and services for community mental health today. Chapter authors include researchers but also practitioners from different disciplines, administrators, managers, and policy analysts who can also speak with the voice of experience. We think this research update is important. Promising service interventions and models of care require research and evaluation if they are to help us to understand what is going on, who is being treated – and who not – with what result in what context and with what treatment modality and range of services. An update and overview of salient aspects of that research forms the subject matter of this collection. We also hope that the collection will be important for practitioners, health planners, and programmers, because the treatment of persons with mental illness cannot be dissociated from the social grounding that is so much involved in clinical outcomes. And, importantly, solutions to the problems of persons with mental illness in the community require a systemic approach. The medical dimensions of treatment are certainly important, but they will bear little fruit without meaningful therapeutic engagement and a more broadly conceived sense of social connectedness and service linkages. This collection begins with a background piece by Stephen State that brings forward the long trajectory of community mental health treatment. In it, he addresses some possible misconceptions about the history of de-institutionalized community mental health services, a history that extends much further back than is commonly thought. The first substantive topic – and one that is implicitly involved in many others – is Evelyn Vingilis’s analysis of the methodology of program and policy evaluation of mental health services in community settings (chapter 3). Her principal message is that we should reconsider our inflexible adherence to the model of the randomized

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controlled trial (RCT), which has been the sine qua non of acceptable clinical trials in other areas of medical research. She counsels against attempting to squeeze the messiness of real-world community settings into the framework of the RCT. Her recommendation, instead, is to make use of newer multi-methods research methodologies, which, if done properly, can give us credible answers to the important research questions. Although the focal context for community treatment is now largely non-institutional, the hospital has not lost all relevance for persons with mental illness. The general hospital, in particular, remains an important part of the community service environment, as Beth Mitchell points out in her chapter (chapter 4). Both at early onset and, given the characteristically chronic nature of mental illness, in the course of subsequent acute episodes, persons with mental illness will find themselves directed to the emergency departments or outpatient clinics of a local hospital. The hospital will continue to have an important gatekeeping function, and it will contribute important oversight in the provision of stepped care within the community. A better understanding of what contributes to the performance of these ongoing hospital functions is therefore of considerable importance. Among the significant drivers of de-institutionalized treatment of persons with mental illness was the spirit of the rights movements in the postwar period expressed in, among other things, the United Nations charters of human rights. The paternalistic confinement of persons with mental illness to long-term in-patient care seemed glaringly at odds with the growing priority placed on human freedom. Nevertheless, the very genuine concern that persons with mental illness should not harm themselves or cause harm to others has led to policies of involuntary treatment and in some cases commitment – even in the absence of any criminal activity. Moral paternalism is always a “tough sell” in liberal societies, notwithstanding John Stuart Mill’s assertion that “those who are still in a state to require being taken care of by others must be protected against their own actions as well as against external injury” (Mill 1982, 69). In his chapter on community treatment orders (CTO s), Richard O’Reilly – himself the principal investigator on one of the largest clinical studies of mandatory orders – examines this controversial topic (chapter 5). He contends that the effectiveness of the CTO has yet to be completely established, although it does hold some promise in reducing hospital utilization and the likelihood of victimization. He recommends

Introduction

9

further research to identify both the most appropriate models of CTO and the most appropriate patients. A similarly troubling aspect of community treatment has been labelled under the rubric of criminalization. In the wake of deinstitutionalization, alarming numbers of persons with mental illness were identified in jails and prisons, which some observers attributed to excessively liberal policies (Abramson 1972); others to the sometimes strange and therefore misunderstood behaviour of persons with mental illness in the community; still others to the prevalence of survival crimes by persons with mental illness as they struggled in communities that provided little in the way of support. In their chapter on this topic, Virginia Hiday and Heathcote Wales argue that we would be well advised to distinguish the very different categories of criminal justice involvement by persons with mental illness (chapter 6). At one end of the spectrum are those whose symptomatic behaviour is the substance of their conflict with the criminal-justice system. This category corresponds with early assumptions about who was being criminalized and why; here the authors contend, uncontroversially, that such persons should be re-routed to the treatment and services they need for successful community integration. Those whose illness causes them to assault others, however, are more properly candidates for extended care in secure facilities. Still others, whose mental illness is secondary to other criminogenic factors in their lives (Junginger et al. 2006) would likely require more than diversion to treatment and services alone. In these cases the causal influences leading to criminal activity may well involve dimensions of their family background and neighbourhoods that cannot be addressed exclusively through psychiatric treatment. Connected to the issue of criminalization is the sensitive and complex relationship between mental illness and violence – with its attendant challenge of risk assessment. Authors Anne Crocker, Gilles Côté, and Erika Braithwaite (chapter 7) provide a concise overview of the research on the risk assessment of violence and the management of it in mental health services. As they point out, the burden of assessing and managing the risk now extends very broadly in the era of community treatment and is no longer confined to the forensic psychiatric system. With liberalizing changes to civil and criminal law, violence and aggressive behaviour, which are exacerbated by substance abuse and addictions, are increasingly common at psychiatric hospital admission and out-patient mental health services. This

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co-occurring population is especially problematic, since the addictions can impair the receipt of services; hence, the need for effective tools of risk assessment and management that combine the static factors of actuarial analysis with the more patient-specific and dynamic clinical analyses that make risk management a practical possibility. It is one thing to compute the probability of future behaviour based on a basket of risk factors; it is another to manage risk so as to permit the treatment of individual patients who may recover and thus reduce their risk profile. Another important message here concerns the need for more studies of implementation; the authors see a worrying gap between experimental studies that validate given instruments and more naturalistic studies that examine the use of risk assessment and management instruments as implanted in realworld, clinical settings. The authors include an analysis of the effect of changes to the Canadian Criminal Code on the practice of risk assessment and the way in which criminal responsibility is operationalized. They note that large numbers of persons who have committed severe and violent offences are now handled in mental health service systems other than secure forensic facilities. For that reason non-forensic psychiatrists in the civil system are increasingly challenged by what are de facto forensic cases. Their examination of the research on specific instruments to ascertain and manage risk will be of interest to program managers and clinicians in both the civil and the forensic systems. A particularly troubling and seemingly intractable dimension of the care and treatment of persons with mental illness in the community is the phenomenon of stigma, whereby persons with mental illness face strong negative attitudes from others and sometimes internalize or anticipate these negative responses as part of a debilitating self-image. Not only is this pattern unfortunate for the person with mental illness, but it also undermines the prospects for clinical improvement and social adjustment. Ross Norman’s thoughtful analysis of the research and the issues in play here (chapter 8) is a useful contribution to identifying the precise problem and moving the research agenda towards programs and policies that might help. Doing so is important because even well-meaning programs can, as he points out, increase the very preferences for social distancing – one dimension of stigma – that they are designed to reduce. Norman identifies a number of very specific areas where targeted research could help. For example, strategies emphasizing the biological causation of

Introduction

11

mental illness or encouraging certain modes of contact with persons who have mental illness have proved counterproductive. He therefore recommends testing other ways of describing the etiology of mental illness or testing alternative modes of contact with persons with mental illness, in order to avoid increasing the social distancing that has resulted from these earlier strategies. In the 1970s, a group of clinicians at a psychiatric hospital in Madison, Wisconsin, believed that persons who suffer from severe and persistent mental illness should be given the opportunity to live in the community through the receipt of community-based intensive treatment, rehabilitation, and support, rather than remaining on long-term wards in psychiatric hospitals. Their idea, in effect, was to take the kind of wrap-around care that a patient might receive on a hospital ward and to reposition this intensive, interdisciplinary multi-faceted care to the community setting. This program evolved to be called Assertive Community Treatment (ACT) and has been replicated and modified in numerous jurisdictions world-wide. Joan Bishop, Steve Lurie, Lindsay George, and Robert Wales examine the efficacy and effectiveness literature on ACT and describe successes, issues and challenges with it and its evaluations (chapter 12). Their chapter concludes with recommendations for future research to help us understand how and why ACT works. The ACT model is very much an interdisciplinary and collaborative model of care, but other expressions of collaboration have come to the fore in the era of community treatment. Raj Velamoor and Stephen State explore models of collaborative mental health care in the primary care domain (chapter 11). Family physicians are very much on the front lines of treatment, yet the long-standing model of the single-provider practice, in particular, has not been well suited to the kind of care needed by persons with mental illness. As their marshalling of the evidence indicates, treatment and outcomes are sub-optimal for persons with mental illness treated by primary care physicians, and the physicians themselves report lack of confidence in treating mental illness. The movement to more collaborative models is plausibly designed to redress identified shortcomings, but this is also a systemic problem of resources and funding. If treatment as usual is problematic, it might well be because there are insufficient specialists and care managers in the ambient health care system. Family doctors are often gatekeepers to the stepped-up specialty care that some patients require, and unless there are effective resources on

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the other side of that gate – or added to the family practice itself – improvements in care are unlikely. Applied research and evaluation to locate cost-effective models of primary mental health care delivery is therefore important for the entire health care system. For consumers, this book provides an understanding of what research is telling us within the various sectors of community mental health services. Consumer/survivors are all too aware of the challenges they have in accessing appropriate and wanted health care for their illness. However, their needs move beyond health care. They also need to navigate complex and sometimes contradictory, federal, provincial/state, and local bureaucratic systems to obtain a range of other services, such as housing, employment, and so forth. This book, although not a guide to system navigation in any given jurisdiction, will offer information on what we know has been successful and what still needs to be researched. In that sense it provides material to support informed advocacy – a window on where we have come, what still needs to be done, and what might be possible to do now – and, importantly, what has been shown not to work. In their chapter on consumer participation in mental health services (chapter 9), Geoffrey Nelson and Jill Grant go much further than this. They provide the background to the current movement for increased consumer participation, exploring its meaning and historical setting. They contend, controversially, that the problems in mental health care may have less to do with service and treatment gaps and more to do with the very understanding of the problem that these services are designed to address. They make the case for transformative over merely ameliorative change, invoking a shift in focus away from a problem construed in terms of patients in need of (better) professional care to one construed in terms of consumers who are “active participants in planning, services and research, with real power, voice, choice and control.” They go so far as to question, in the tradition of Foucault (which some might see as paradoxical), the very science that underscores the research that is designed to achieve better programs and outcomes. Housing is a key determinant of health, playing an important role in the quality of life, health, and overall well-being of persons in a community. Nevertheless, housing has historically not been seen as part of the general health services sector. Yet for persons with mental illness in particular, numerous barriers can exist for the provision of adequate

Introduction

13

housing. The barriers can be person-related and environment-related. To add to the complexity, barriers emanate from different sectors and levels of government and are also rooted in societal attitudes. In her chapter on housing and mental illness, Cheryl Forchuk outlines the common barriers facing persons with mental illness in accessing appropriate housing (chapter 10). She also examines the policies that have impeded the development of appropriate housing options and describes best practices and future research questions that need to be tackled. Eric Latimer’s chapter on supported employment (chapter 13) addresses a similar issue of great importance to the quality of life and social engagement of persons with serious mental illness. As he points out, although very few do in fact work, a majority indicate their desire to do so. The benefits of paid employment, in particular, are considerable in terms of self-esteem, symptom improvement, financial well-being and recovery. Early models of employment support – beyond the sheltered workshop, which effectively isolated the patient from the community – typically began with skills training, so as to make the client more attractive to prospective employers. In the early 1990s a new model of supported employment began to show promise in evaluations: the “place-train” approach. Here, instead of starting with training and moving to job placement, persons with mental illness would be placed directly in a position of employment and then supported with a vocational advisor to learn what the job required. One formulation of this model, the individual placement and support (IPS) variant, has in particular stood up well to evaluations, as Latimer shows in his thorough synthesis. However, as he points out, since even this model does not work for everyone, it is also important to explore alternatives that meet the needs of those who are not well served by the IPS approach. We would add that in the era of community treatment, addressing the needs of persons with serious mental illness will typically involve considerably more than a prescription or a few brief therapy sessions by a treatment provider. Interventions typically include a wide range of ancillary services beyond what takes place in hospital and clinical settings, including case management, assertive community treatment, social work, criminal-justice diversion programs, mental health courts, mobile crisis teams, specialized emergency room protocols at general hospitals, specialist psychiatry support to primary care providers, employment support, supervised housing, and

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peer support. It will also require a profound cultural change that addresses the stigma facing – and often internalized by – persons living with mental illness. A final introductory point concerns terminology.2 The choice of terminology is situated within an “essentially contested” (Gallie 1955) conceptual arena with a lengthy history. In the late eighteenth century William Tuke’s York Retreat provided for the moral management of those who would probably be termed lunatics in pointed rejection of the medical model of illness entertained by the contemporary profession of “mad doctoring.” As distasteful as the term lunatic might be now, it probably conveyed no additional prejudice at the time beyond contemporary understandings of what that misfortune entailed. By contrast, in the early twentieth century, practitioners like Maudsley sought to treat persons with mental illness much as patients with other diseases would be treated, in the wards of general hospitals and on a voluntary basis. This approach was widely considered both humane and progressive, entirely in line with the new mental hygiene movement and the psychopathic hospitals that that movement spawned (see chapter 2, on the historical background). It is hard to imagine how the terminology of “mental hygiene” or “psychopathic hospitals” could get any positive traction today. On the other hand – and many hands are needed here – advocates of the anti-psychiatry movement do not consider psychiatric ailments to be illnesses at all, a view shared by some observers in the recovery movement. Some prefer the term consumer, connoting perhaps the dimension of choice and control over treatment decisions in the manner of an informed shopper deciding to buy one product instead of another. Again, some consumers also refer to themselves as survivors, in the sense of surviving the involuntary treatment – less common now – that was typical of the large mental hospitals before the 1960s. Every choice of terminology, it would seem, has some problem. The term “patient” seems out of place when treatment is less frequently received on an in-patient basis. Yet many care providers – psychologists, psychiatrists – do refer to the people they treat as patients. To use the phrase “person with mental illness” will offend those who find the medical context inappropriate. Nevertheless, many rely on that medical terminology when the concern is to absolve people of responsibility for criminal behaviours or to reduce the social stigma of, say, addictive disorders. To change the word illness to disability or

Introduction

15

disorder is similarly problematic: some persons who live with the condition may resent the negative terms of dis-order or dis-ability. They may see themselves as people with idiosyncratic and creative understandings of the world. The terms client or consumer have problems also. Although they focus attention on the choice of an agent to decide on what treatment to accept, they render mysterious the reasons for making any consumer choices at all in the shopping market of available treatments. The term survivor is equally ambiguous, since it is not clear what has been survived, the disorder or the treatment. We have chosen for our introduction the phrase “persons with mental illness.” We concede that this choice of medical terminology implies that psychiatry and ancillary modes of care and service do appropriately deal with illness. Nevertheless, we would emphasize that a person is more than an illness, no matter whether the illness is cancer, diabetes, or schizophrenia. We have left it to individual authors of our collection to choose the terminology they deem most appropriate.

notes 1 We have included a chapter on consumer involvement because there is now a large body of research findings to examine and evaluate. 2 These issues of terminology are nicely discussed by Simon Davis (2006).

2 Community-Based Treatment: A New Idea a Hundred Years and More in the Making Stephen A. State Deinstitutionalization Is Aging The “deinstitutionalization” label as applied to a process of change in the locus of delivery of mental health services from institution to community is now approaching at least half a century of continuous use. Its precursors are older still. If we quite plausibly included the guiding ideas of the 1915 Maudsely Hospital in London, which included out-patient treatment of voluntary patients (Jones 1993, 126), and the very similar ideas underlying the Boston Psychopathic Hospital’s outdoor programs inspired by the mental hygiene movement circa 1910, de-institutionalization would be approaching its centennial. Or if we were to include the programs and practices of the Mental After-Care Association in the United Kingdom, which date from 1879 and which provided care in the community for patients discharged from asylums (Jones 1993, 127), the idea in 2010 would be over 125 years old. Finally, if we noted the evidence provided by Bartlett and Wright’s collection of research (1999) showing significant treatment of persons with mental illness in the community outside the walls of the asylum in eighteenth-century Britain, we would see that the novelty of community-based treatment is well-worn indeed. Connoting, as it does, the shift of patient populations from institutional care to treatment in “the community,” the label is also somewhat misleading. Most people with serious mental illness now treated in the community would not typically have spent prior lengthy periods of hospital confinement before community-based treatment. If anything, less-invasive treatment close to home would likely have

Community-Based Treatment

17

predated any period of usually temporary hospitalization. Yet if the label is misleading the trend is clear: community treatment is now the virtually universal norm for persons with serious mental illness. But what is community treatment and why did it come about? The phenomenon of de-institutionalization can be observed in England, the United States and in Canada. The chronology of the United Kingdom narrative (Hoenig and Hamilton 1969) may be somewhat different from that in North America, but the net trend is similar. In the United Kingdom, small private institutions called lunatic asylums and operated by “mad doctors” were already prevalent by the end of the eighteenth century. Treatment varied along a grisly continuum (Scull 1989, 75) of coercive and forceful measures designed, irrationally, to reposition reason to its proper place in the patient so brutally treated. There were similar private hospitals for the “insane” in the nineteenth-century United States. Writing in the Journal of Insanity in 1864, Dr Ray describes the treatment model of these American hospitals: the main fundamental idea was to break the patient’s will and make him learn that he had a master; to teach him that there was a mind and physical strength there all superior to his own … That was the principal object to be kept in view, and it was to be gained at any risk. If fair means would not do, other means should; if strong words or curses would not answer then resort was had to the knock-down arguments. This was thought to be the proper way; no secret was made of it, and the friends of patients understood it perfectly well … Among the methods of treatment … was the process of submersion and the idea was, probably, that if the patient was nearly drowned and then brought to life, he would take a fresh start, leaving his disease behind (Hurd 1916, 585). Despite public criticism of their barbaric practices (Jones 1993, 54) the asylum idea continued to grow, but its growth had nothing to do with mad-doctoring. The idea of removing the person with mental illness to a separate space was due in large measure to a small Quaker institution in England called the York Retreat. It was begun by the layman William Tuke in 1796 and replicated shortly thereafter in Philadelphia.

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The Asylum This first wave of institutionalization – the asylum movement – is itself something of a misnomer. It was really a movement to a different kind of institutional care, rather than a shift from no institutional treatment at all – although, as noted above, there were already – and continued to be – some not inconsiderable expressions of care in the community at the same time. The famous retreat developed by Tuke was meant to replace obvious mistreatment at the already existing York Asylum (Scull 1989). The new retreat was premised on the assumption that the ambient community – including the patient’s family – was the problem giving rise to mental illness and that the right kind of institution would be the solution (Scull 1989, 304). This was emphatically and self-consciously not a medical model of care; Tuke, who was a tea merchant, had considerable skepticism about the medical treatment of the mentally ill at the time (Edginton 1997, 92). Later, ironically, it was the “non-medical” practice of moral treatment pioneered at the York retreat that “alienists” (to use the nineteenth-century label for doctors specializing in the treatment of mental illness) would incorporate into the medical best practice of the nineteenth century. Tuke’s retreat would replace the brutality of mad-doctoring with a “moral” regimen of fresh air, good food, engaging activities, and dignified treatment by compassionate staff: a gentle and bucolic haven from the madding crowd and the family and community that had caused the problem in the first place. The humane treatment to be afforded by a humane institution – far away from the community – would contribute to recovery. Frequently, a liberal dose of porter was also prescribed. The asylum movement in the United Kingdom grew rapidly on the promise of the sort of institutional care that the small retreat might offer. Recent examinations of patient records from the nineteenth century suggest a surprisingly positive and community-oriented picture: Approximately 40–50 percent of patients admitted to public (lunatic) asylums in the nineteenth century stayed twelve months or fewer. Only about one in five patients were ever readmitted, and admission orders reveal that the “attack” of insanity had often been underway for months, if not years, before confinement took place. These arresting findings imply

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that situations of “care” in the community existed long before a crisis precipitated institutional confinement, and continued after discharge. Care outside the walls of the asylum was therefore a reality, not only for those suffering from madness who were never admitted at all but also for those patients who were confined in mental hospitals only for short periods of their illness. (Bartlett and Wright 1999, 3) The promise of humane care was difficult to sustain. Instead of the 150 to 200 patients per retreat living lives of rural ease, the numbers of patients grew beyond any plausible prospect of humane treatment and beyond the ability of the public to fund. The anticipated, muchvaunted cure rates never materialized. Legislative reforms in the County Asylum Act of 1828 sought to provide broad standards and oversight, but it was a losing battle. Asylums became overcrowded, growing into the thousands of patients and adding wing after wing. By the time Dorothea Dix (Dix 1845; Gollaher 1995; Brown 1998) was making the case for asylum care in mid-nineteenth-century North America and throughout continental Europe, the asylums in the United Kingdom were coming increasingly under attack for failing to provide the sort of care that justified their construction in the first place. Indeed, by 1830 John Conolly – although an exception – was beginning to question the very idea of widespread institutional care (Scull 1989; Conolly 1830). In Canada, the influences shaping the models of care for those with mental illness have come from both the United Kingdom and the United States, but in the case of Québec (Paradis 1997) and other francophone centres, also from France. At the time of the revolution in France, Phillipe Pinel at the Bicêtre Asylum in Paris was humanizing the care of the mentally ill in a way that bore resemblance to Tuke’s asylum in York. The iconic image of Pinel, liberating inmates of the asylum from all forms of restraint, however, is surely inaccurate; he continued to advocate the use of straight-jackets for patients under his care (Weiner 1992) “to dominate agitated madmen while respecting human rights.” In that sense, the approach of Pinel is slightly different from the Tuke model: Tuke’s approach would simply remove the pathological community and family influences that had, he thought, caused the problem and allow the wholesome environment of the retreat and the person’s interaction with it to foster recovery. Some of the practices at Pinel’s asylums – particularly those involving

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constructive activities by clients – were similar. Unlike Tuke, however, Pinel also proposed to alter the mental status of his patients with what was a medical intervention, a kind of talk therapy. It was, of course, a very different psychological intervention from the viciously physical methods used by others at the time. Pinel’s humane methods were cited in a report to the House of Assembly of New Brunswick in 1836–7 in the course of discussions there on reforming asylum practice. The same report reflects the consensus on preferred treatment in nineteenth-century Canada, this time drawn from an American source reflecting, in turn, the principles of the York Asylum in England: there should be dairy rooms, workshops and store-houses, all arranged for the particular object of employing them; they should be engaged (in times and seasons for the several labors) in cutting, making and loading hay; planting, sowing, cultivating and getting in garden and field crops, collecting and storing away fruit, shelling corn, dressing flax, tending stock, milking cows, making butter and cheese, knitting, sewing, etc.; in fine, all the labors of a large farming establishment, besides various mechanical labors. ( Hurd 1916, 4:83) In Quebec, a report of a special committee of the Legislative Council of Lower Canada, 1824, criticized the “deplorable condition” of the insane in the province. A description of the existing situation at the Ursuline Nunnery in Trois Rivières circa 1823 included these observations: there are 6 cells, of the size of about 8 feet long, 6 feet broad, and 8 feet high … Each of the above cells is intended for one inmate, who is solitarily confined therein, day and night, with few exceptions, and only removed therefrom to another cell when … cleaning. [once in 8 days] The cells have each a small glazed and grated window in the outside wall, of about a foot square; and in the passages there are openings above each door, also grated. Through these windows light is admitted, and, when opened, air. There are stoves in winter in the adjoining passages, which heat the cells; and in summer a window at each end of the passage admits air; but the ventilation must be very imperfect. (Hurd 1916, 4:252–3)

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A temporary expedient of managing those with mental illness in the Montreal jail was particularly criticized by Dorothea Dix, who entered the fray in Upper and Lower Canada – and later in Nova Scotia – in support of the asylum movement (Moran 1998). The response would be a call for the new “improved modern system” of moral management and institutional care that eliminated or minimized physical restraint. The trend to institutionalization in Quebec, was also distinguished by a tradition of “farming out,” or capitation,1 whereby enterprising groups and institutions would bid for the contract to manage and house the insane for a given region at a rate of so much money per person per year. An example, on a large scale, was the asylum at Beauport, near Quebec City, which was contracted to a consortium headed by James Douglas,2 who soon bought out his other partners. Douglas was the nominal medical director, as well as the proprietor, and the $132 per person he collected from the state enabled him to spend the winter months in Italy, Egypt, and Palestine (Hurd 1916, 4:268; Moran 1998; Grob 1983, 428). The obvious conflict of interests at Beauport led to a number of scathing critiques. One was by Daniel Hack Tuke, a descendant of the founder of the York asylum, and another equally damaging critique was by Joseph Workman, medical director of the Toronto asylum. The pressure eventually led to Douglas’s departure and the replacing of the contract at a lower rate, with better results. Interestingly, Quebec maintained a number of other treatment options for those with mental illness, some of which involved management in the community by “the use of the local jail, boarding out, family management [with] … neighbourhood supervision [through] the use of local nurses and physicians” (Moran 1998, 309). The general nineteenth-century trend in Canada, however, whether influenced by British, French, or American advocates, was so-called moral management, which took place in increasingly larger asylums. Throughout most of the century this largely custodial practice was the consensus treatment for those with mental illness in the United States, England, and Canada. In the early twentieth century a very different practice would take shape.

Community Psychiatry and Mental Hygiene At the time of the First World War the asylum system in the United Kingdom was in tatters. Some of the larger sites were reconstituted

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as emergency war hospitals, which exacerbated problems of overcrowding; 42 percent of staff left for war duty; many were killed. Tuberculosis rates in the remaining asylums reached horrific levels (Jones 1993, 124). In 1915 a qualitatively different sort of centre for the treatment of mental illness had taken shape in the new Maudsley Hospital (Rollin 2003, 294). Maudsely’s institution was used first as a military hospital, but it was meant for and subsequently adapted to civilian use in 1924. His idea was to treat persons with acute and early onset mental illness primarily on an outpatient basis through urban teaching hospitals connected to a university with a significant focus on research (Jones 1993, 126–7). Importantly, the treatment would take place without involuntary commitment. Those with mental illness would be de-segregated (as it was called in the United Kingdom circa 1918), and mental illness would be dealt with as a category within general medicine to be treated in community catchment areas of general hospitals. At the time, oversight of the large asylums was vested in a board of control. In a special report to an ad hoc Government Reconstruction Committee in 1918 (Jones 1993, 127), the board recommended many of the principles that underlay Maudsley’s hospital. Whereas the Tuke-inspired asylum sought to escape the community and the mad-doctors, this prescient 1918 report would reverse both of those goals. Those with mental illness would be treated in the community where possible; they would be treated primarily by the practitioners of the branch of medicine specializing in their treatment and care. The Macmillan Commission (U.K.) of 1924 – set up largely as a result of reports of scandalous treatment in the large county asylums – concurred; moreover, their report reinforced the need for discharge planning and for systems of care to aid in successful community tenure (Jones 1993, 133). This movement toward community treatment continued in the United Kingdom through the interwar period, although it was not until the mid-1950s that significant changes came about (Jones 1993, 150 and passim). In North America it was also after the Second World War that successful pressures arose to de-institutionalize the mentally ill. Before then, both Canada and the United States were moving to embrace the large provincial or state mental hospital as the preferred segregated venue for mental health treatment. Nevertheless, there were also significant voices in North America speaking of a different, more community-focused direction in the provision of mental

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health services. One was the discipline of neurology, which led to Maudsley-like psychopathic hospitals and psychiatric clinics connected to general hospitals in the community. The other was the mental hygiene movement. In the former case, psychiatry as neurology had very decided biomedical, scientific aspirations; it looked to the anatomy of the brain to address the issue of mental illness. The premise was that mental illnesses like “mania” or “hysteria” might be identified and treated in the manner of cerebral hemorrhages or amyotrophic lateral sclerosis – by locating the physiological drivers of the disease (Stein 2004). TaySachs disease and syphilis were instances of diseases that neurology had successfully identified with objective bio-medical markers – even if there were at that point no treatment implications. Syphilis was significant in this regard, since a late stage of that disease was associated with dementia. As early as 1869 a neurology clinic had been attached to the Bellevue Hospital Medical College in New York. An institutional expression of this new trend was the renaming of the Association of Medical Superintendents of Institutions for the Insane to the American Medico-Psychological Association (Grob 1983, 69). Like the neurologists, the mental hygiene movement in the United States and Canada maintained that institutionalized treatment was not necessary for everyone with mental illness. Unlike the bio-medical focus of neurology, the mental hygienists held that mental illness was caused largely by environment and social pathologies. In identifying environmental stressors, they agreed with the earlier asylum movement; unlike that earlier movement, which sought to take the person out of society, they proposed to change society. If psychopathological determinants could be addressed through psychiatric social work, juvenile reformatories, occupational therapy, and other broadly social modalities, there would be significant reductions in prevalence. As well, if cases could be found and treated early, cure rates would be greatly improved. Although there was still little consensus on what mental illness was or on what caused it or even on how to label it, both the new neurologists and the mental hygienists were equally enthusiastic in promoting activities designed to prevent it (Grob 1983, 157). In the case of the mental hygiene movement, the inspiration was the recovered patient of a mental hospital in the United States, Clifford Beers, whose book A Mind That Found Itself achieved international acclaim (Beers 2004). Beers’s complaint had been that

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he was improperly treated in a heavy-handed way in an asylum near Boston where he was involuntarily committed. But what emerged in the advocacy movement that followed was not more sensitive and caring treatment in an asylum; it was a radically different sort of treatment through a different kind of hospital (Grob 1983, 161).

The Psychopathic Hospital The July issue of the Canadian Journal of Mental Hygiene for 1920 contains the address by A.G. Morphy to the Montreal meeting earlier that year of the Medico-Chirugical Society, outlining the principles of the Psychopathic Hospital that had been coming on stream in the previous two decades: it must of necessity be in the centre of things, not removed to a secluded spot like a hospital for the insane. It is the centre of a co-operative system consisting of general hospitals whose specialists are called in for consultation, of social workers who are in touch with the public through the various Social Agencies found in a large city, of all the associations connected with the proximity of numerous colleges and hospitals, of its own visiting staff who attend the out-door department, of the laboratory research work being carried on under the commission on mental diseases, and last but by no means least, the police. The conclusion that this accessibility and co-operation work together for the good of the patients and for the advancement of science is so inevitable that it hardly needs to be mentioned. (Morphy 1920, 172) This was a very different point of view from that of the asylum managers at the end of the nineteenth century and afterward. Although the moral management of patients had come to dominate the thinking of the medical superintendents of the large asylums, the kind of medicine practised was not very advanced, and the management not very “moral.” The great success by Joseph Workman at the Toronto Asylum is mostly linked to his efforts in repairing the ventilation, heating, and sewage systems in the new buildings so that patients did not die from diseases resulting from unsanitary conditions (Brown 1980, 99). Most of the challenges faced by medical superintendents

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were those of administering and managing the thousands and thousands of patients and custodial staff who lived and worked in enormous institutions. A revealing contrast can be noted in two contemporary hospitals in Manitoba. In 1918 the Brandon, Manitoba, asylum had one medical doctor for its 713 patients, and he, the medical superintendent, “was generally tied up with administrative affairs, especially managing the asylum farm, and left the care of the patients in the hands of the matrons and attendants, whose major concern was order and not cure” (Edginton 1988, 180). Most patients were brought to this remote asylum in shackles, and according to the report by Clark and Hincks of the Canadian National Committee for Mental Hygiene, “it was a place of utter futility and idleness, with patients looking to death for their freedom” (Edginton 1988). In contrast to the patient warehousing practised at the Brandon asylum, the director of the Manitoba Psychopathic Hospital in Winnipeg, A.T. Mathers, would present his institution as a community social service, most of whose patients were treated voluntarily: “the four walls of the hospital do not limit its activities. They can never again be an obstacle to that shuttle – social service – that constantly works back and forth between the hospital and its community … The Psychopathic Hospital is the centre of a circle, the circumference of which is coterminus with the boundaries of the community itself” (Mathers 1921, 177). Other psychopathic hospitals and psychiatric clinics associated with general hospitals had opened in the first two decades of the twentieth century, including in Toronto, Montreal, and Winnipeg in Canada. Scull describes the community-oriented argument in support: “instead of a monolithic asylum system, they [progressives] proposed a network of psychopathic hospitals providing expert diagnosis and intensive treatment for recent curable cases; a massive effort to provide outpatient clinics and aftercare services for those discharged from the hospitals; financial aid, augmented by psychological support and counseling; and a new emphasis on preventing the outbreak of mental disorder through public education in mental hygiene” (1989, 255). There were other expressions of community mental health service delivery at the time. In addition to the psychopathic clinic, another form of community care more common in Europe – and one pioneered in North America in Massachusetts in 1885 – was that of family

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care. This model had precedents going back to Gheel, Belgium, in the Middle Ages, where chronic cases would be cared for in families other than their own with oversight provided by the hospital or public health professional (Crutcher 1939, 180). Ontario pursued the practice from 1932; some five hundred patients were in family care by 1938. During the same period the New York Department of Mental Hygiene maintained in family care a number that “would more than fill a small institution” (Crutcher 1939, 180). Some jurisdictions, including a number of American States, followed a similar practice of parole (Grob 1983, 316) for patients in transition to the community from in-patient care. There were also travelling clinics that followed the principles of the mental hygiene movement. Ontario set up six such clinics in the 1930s to reduce the numbers of admissions to the provincial mental hospitals. Much of their activity was involved in the assessment of children for adoption and of various juvenile behaviour disorders (Blom and Sussman 1989, 131–3). In practice, they succeeded more in locating new cases in need of in-patient care, since they lacked the resources to achieve much in the way of cure or prevention (Simmons 1990, 48–50). Despite these significant forces – psychopathic hospitals, the mental hygiene movement, and operational models of community treatment – the overwhelming trend continued to be the large segregated and largely custodial mental hospital. Even during the Depression they continued to expand. In Ontario in 1939 the St Thomas Mental Hospital opened its doors to over a thousand patients, a small number in comparison to others. In 1931, the State of New York opened two new asylum-like mental hospitals, Rockland State3 and Pilgrim State. The former had a capacity of 3,900 patients; the latter could hold 7,831. Across the United States in 1935 the total expenditure for all types of mental health care was estimated at about $182 million, and 90 percent of this was spent on in-patient mental health care in the large asylums. Only 3 percent was spent on psychopathic clinics, and 7 percent on services of physicians in private practice. Less than a quarter of 1 percent was spent on activities connected with the mental hygiene movement (Davis 1939, 166). Various reasons are suggested for this continued growth in institutional care. One factor is simply that of program and policy momentum. The large state-run mental hospitals were massive juggernauts of bureaucratic inertia. In the case of general illness in the United States, 80 percent of the costs at this time were covered by

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patient fees; in the case of mental health care, 75 percent of the costs were covered by government expenditures, primarily through the large mental hospitals. Consumers and their families would be caught in a bind: if they pressed for community care as available at the time, they would have to pay for it; the state hospitals for the insane would take in everyone regardless of their ability to pay. As well, the state would typically have assumed control of mental health care after city and county operations, on the basis of capitated carve-outs, had bid down the costs for service delivery to levels that could not support adequate care. The per capita costs of in-patient custodial care were far less in the short term than more intensive therapies proposed by advocates of the new psychopathic hospitals – 74 cents per person per day compared to $5 or $6 per person per day (Rorem 1939, 221). Writing in 1939, A.P. Noyes could say with conviction that “[i]n no state where county or city care of the mentally disabled has been superseded by state supervision would the citizens permit return to the former system” (1939, 292). Community care looked to be expensive. Others have blamed the administrators of the large institutions and their desire to protect their turf (Rothman 1971, 6). Rothman’s evidence notwithstanding, that is not the full story. Some representatives of those very hospitals were making the case to transform them into centres of community psychiatry. Indeed, in the 1960s when the new Community Mental Health Centers were set up in the United States, a few were organized through the state mental hospitals, where the hospital had “long been a principal mental resource in its area, and hence it was quite reasonable for the hospital to develop the center independently” (Levenson 1969, 84–5). If it did its job properly, one commentator from the mental hygiene movement wrote, the mental hospital would be “the community department of psychiatry” leading the breakdown of departmental silos and placing the needs of the patient at the centre of its responsibilities (Stevenson 1939, 336). The director of the Danville State Hospital in Pennsylvania in 1939 considered that the “phrase ‘mental hospital and the community’ therefore has a significance and meaning today which it did not and could not have during the asylum period, when institutions for the mentally ill … were isolated from the main stream of community life and served largely as convenient receptacles for the custody of an unfortunate group that received, at best, humane care but little, if any, medical treatment” (Jackson 1939, 331).

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Alas, these remarks in the majority of circumstances seem like cognitive dissonance: more an expression of hope than fact. Contemporary observers more commonly noted that the large mental hospital belongs to and feels for no one community because it serves many communities. Its distance from its communities has even affected its work on its traditional patients. For example, it is half a century since we came to appreciate the value of knowing the home setting of mental hospital patients, of discharging the patient into a suitable environment, and of continued aftercare treatment (follow-up) in the community after discharge. These community responsibilities have been recognized as important to the patient … [but] are not today generally provided as a part of psychiatric service to a community. (Stevenson 1939, 337) The director of the Commission on Hospital Service for the American Hospital Association remarked in 1939 regarding the large mental hospitals that he “would like to [express] gratification that hospitals with 5,000 or 6,000 patients can render any degree of personal or scientific services to the mental cases under care. To a layman it is unbelievable that intensive personal service necessary to the treatment of mental cases can be rendered to such large groups of persons … It is a wonder that the care is of any value at all”(Rorem 1939, 221; emphasis in original).

Community Treatment as the Norm Why, then, did things change? Simple explanations for the eventual trend are hard to come by, and most explanations vary to some extent by jurisdiction. The arrival of lithium and psychotropic medication is often cited with good reason as a contributing cause, yet accelerated discharge rates and reduced average length of stays have been documented earlier than the introduction of these drugs (Grob 2004). The financial constraints arising from the Depression and the Second World War, both of which led to declining standards of care, were certainly a factor. As noted, in some cases the hospitals themselves were already imbued before the Second World War with the spirit of the mental hygiene movement. Speaking about the “role of a public mental hospital with reference to the mentally ill of a

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community,” in 1939, Dr J. Allen Jackson specified the requirements of a “well-rounded community service.” They included outpatient treatment facilities, social services, public education programs, and policies directed to the reduction of stigma (Jackson 1939). Some impetus in the post–Second World War era likely came from versions of anti-psychiatry arguments. Erving Goffman, Michel Foucault, and Thomas Szasz all gave academic credibility to “cuckoonest” depictions of in-patient treatment (Szasz 2005) and fuelled patient rights arguments so in line with the civil rights movement of the 1960s and the just society arguments of the 1970s (Grob 1992, 16). In Goffman’s view (1961), the institutions themselves were the likely culprit in protracted mental illness; for Foucault, the asylum was merely the instrument through which society exercised control (1988); and for Szasz, the very idea of psychiatry as a medical specialty was an illusion designed to facilitate the removal from our midst of deviant behaviours. Yet, as we have seen, many of the criticisms of the large mental hospitals were made long before the 1960s, and significant international expressions of community treatment emerged much earlier as well. In the United States, outpatient clinics of community psychiatry became ”widely established” in the 1940s (Glasscote 1964, 4). Advocates like Gerald Caplan and Robert Felix were pushing for preventative, population-based interventions that they dreamed would make most in-patient treatment unnecessary (Grob 1991). The Expert Committee on Mental Health of the World Health Organization recommended in a 1952 conference report that ”community mental hospitals should provide outpatient and part-time treatment, rehabilitation services, and research and community education programs” (Glasscote 1964, 5). This was three years before the introduction of psychoactive drugs in 1955; nine years before the publication of Goffman’s (1961) critique of institutional neurosis, Asylums, Foucault’s Madness and Civilization, and Szasz’s Myth of Mental Illness in 1961 (Szasz 1974 revised). Perhaps, too, the war experience contributed to the mood in support of community treatment (Yolles 1969, 7–8). In the Second World War, surprising numbers of recruits had been rejected from service on the basis of emotional or psychological concerns. In the American context alone, almost four hundred thousand potential recruits had been discharged for psychological reasons. It was also apparent that hitherto healthy individuals might, through the difficult experiences

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of warfare, become mentally ill, be treated and, in many cases, regain their health. In the United States this faith in community-based prophylaxis brought the federal government into play as a significant actor and direct funder of community mental health initiatives. Perhaps since they were treating large numbers of persons with posttraumatic stress disorder (PTSD) in Veterans Hospitals, it was the US federal government that led the charge to community treatment with the 1963 Mental Retardation Facilities and Community Mental Health Centers Construction Act. Through the now infamous “institutions for the treatment of mental disease” (IMD) exclusion, state psychiatric hospitals would be deprived of federal Medicaid funds in order to move the locus of mental health treatment into the community. In their heyday, the US state mental hospitals held five hundred thousand patients; now, with a much larger ambient population, there are barely fifty thousand – declines that are reflected in other jurisdictions in the Western world as well. The US narrative here is akin to a tale of two systems: the deinstitutionalization story of the shrinkage of the large state-run mental hospitals and the story of the federal government’s Community Mental Health Centers. The former was the demoralizing Asylum story, which Goffman had so demonized in his influential book with that name. The latter took most of the hopeful attention – and most of the funding. It was a story of optimism replete with the Kennedy Camelot aura and the principles of community psychiatry that – much like the earlier mental hygiene movement – would make mental illness largely unnecessary. The complexity of this bifurcated story appears in some curious quantitative patterns. The in-patient numbers for the large mental hospitals in the period between 1955 and 1971 show a decline from 558,922 to 308,024, yet in the period between 1966 and 1971 the numbers of admissions to the large mental hospitals actually rose (Martin 1984, 1) from 802,216 to 836,326 (Trotter and Chu 1974, 3), and expenditures rose 54 percent during the same time. Commentators have implied that this was likely a wasteful and unnecessary prolongation of a dated institution. Another explanation for the same data is that the large mental hospitals were becoming centres of short-term treatment of acute episodes of serious mental illness and that persons were cycling back and forth between “the community” because the community – in the shape of the new community mental health centres – did not have the resources or the programs to deal properly with them (Trotter and Chu 1974).

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In England, the story of the move to community treatment of persons with mental illness displays some similarities with the US case. For one thing, arguments for moving in this direction preceded the introduction of neuroleptic drugs, and, as with the US experience with community psychiatry, they were predicated on a socialpsychological treatment modality. In England it was the therapeutic community movement of Maxwell Jones and others (Martin 1984, 3). In addition, by 1949, 90,000 people were already being treated through outpatient community psychiatry services established by local authorities across England. By 1959, the numbers had grown steadily to 140,000. There were also increases in the numbers treated through the general hospitals and day hospitals and declines in the numbers of in-patients (not, as noted, in in-patient admissions). The 1957 Great Britain Royal Commission (1957) on mental illness made clear that the trend in policy goals would be to treat persons with mental illness much like other patients with other diseases: voluntarily and not in segregated specialty hospitals. The Canadian pattern is similar. Arguments in favour of community treatment and some small-scale models of community programs – travelling clinics, family care, for example (Simmons 1990, 48) – were available well before the Second World War. The impetus to change was accelerated with the publication of the influential Tyhurst Committee Report, More for the Mind, a review that appeared in 1963, although the committee to undertake the review had been struck in 1955, four months before the appointment in the United States of the Joint Commission on Mental Illness and Health. Inspired by Canadian pioneers in the mental hygiene movement, the Tyhurst committee would press for “psycho-social rehabilitation and maintenance of the patient symptom free in the community” over “symptom improvement of patients in hospital” (Tyhurst 1964, 31). The report was criticized for maintaining a medical model of care, with the psychiatrist in charge. That citicism is undeniable, but the report also stresses the need to address the social environment, as well as individual psychopathology, to prevent as much as to treat. It very clearly articulates the goal of community re-integration through coordinated community services (Tyhurst 1964). As in the US case, the Canadian federal government provided some incentive for the policy shift from the hospital to the community, albeit on a much smaller scale,. Psychiatric units in general hospitals had been growing in any case. In Ontario, the progression was from 6 hospital psychiatric units with 125 beds in 1954 to

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60 units with over 2,100 beds in 1981 (Simmons 1990, 55–9). Also in Ontario, provincial psychiatric hospital (PPH) beds declined from 219 in 1965 to 45 per 100,000 of the total Ontario population in 1998. A 2004 analysis of Ontario’s PPH s and community treatment programs showed a further decline to less than 10 percent of the 1965 rate (Sealy and Whitehead 2004). Given that the significant numbers of persons with serious mental illness treated in primary care are not captured in the study, the trend to an overwhelming proportion of persons treated outside long-term in-patient wards in psychiatric hospitals is clear. The delivery of mental health services is principally a community phenomenon.

Notes 1 A practice revived in the twentieth century in US jurisdictions under managed care. On the differences between English Protestant and Francophone Catholic approaches to asylum care see Paradis (1997). 2 Douglas’s name would later be attached to the mental hospital at Verdun through significant donations by his son, an American physician who had made a fortune in copper. See Hurd (1916). 3 The author undertook a weekly voluntary service placement at Rockland State Mental Hospital while attending Camp Ramah, a summer camp in Nyack, New York, in 1966.

3 Issues and Challenges in Community Mental Health Services: Program and Policy Evaluation Evelyn R. Vingilis The last two decades have seen the development of a strong movement for “evidence-based” health care. Although a key rationale for evidence-based care has been to provide health care providers and patients/clients/consumers with information about outcomes of the best-evaluated interventions so that they are able to make more informed decisions about care, it is also acknowledged that one driving force behind evidence-based health care is fiscal – the goal is for health care funding agencies to find the most cost-effective health care option (Barnes et al. 1999; Fonagy 1999; Guyatt et al. 1995). The problem of obtaining the “biggest bang for the buck” has become even more salient with concern over escalation of health care expenditures and thus the sustainability of health care systems (Vingilis and Sarkella 1997). The upshot of this concern over escalating health care expenditures has been an increased interest in and emphasis on the evaluation of health care services, with mental health care programs, services, and policies being no exception, although it is important to point out that funds for the conduct of evaluations are still limited. Program evaluation is a relatively new science. It has evolved from many diverse disciplines, such as education, psychology, sociology, nursing, political science, public administration, economics, health sciences, health promotion, and so forth, and as such, the conceptualization, research methods, and language of evaluation have been as diverse as these disciplines. Moreover, program evaluation is an umbrella term used for many different types of evaluation. Even here,

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the terms used for different types of evaluation, such as process, implementation, monitoring, formative, outcome, impact, summative, economic, efficiency – not to mention program rationale – have varied from discipline to discipline. Yet over the past three decades, program evaluation textbooks and articles by scholars within these disciplines have begun talking with a shared conceptualization and methodology (although not yet with the same language). Indeed, even the large divide between quantitative and qualitative evaluation methods has been muted, with many current program evaluation scholars supporting the two research approaches to answer different questions and the ever more popular mixed-method approach (e.g., Caracelli and Greene 1997; Chen 1997; Cordray 1989; Datta 1997; Greene et al. 1989; Greene and Caracelli 1997; Mark et al. 1997; Smith 1997). And although program evaluation texts are more likely to be quantitative (and post-positivist), most include chapters on various qualitative and other research approaches, such as participatory action research. Additionally, a number of renowned qualitative evaluation texts have also been available (e.g., Patton 2002). Yet despite the more clearly articulated conceptualization and methodology that has developed for program evaluation in numerous textbooks, journals, and Web-based handbooks, a number of published evaluations in the mental health services sector are weak and provide limited valid or valuable information for policy-makers, managers, and practitioners (Corrigan et al. 2001; Franx et al. 2008), although it is important to point out that this problem is not exclusive to community mental health services. The purpose of this review chapter is not to review and synopsize evaluations of community mental health services, since the subsequent review chapters on various community mental health issues engage in this enterprise. Rather, this chapter offers current thinking on program evaluation issues and methods in the conduct of evaluations of communitybased outcomes, and it reflects on their current uptake within community mental health services outcomes evaluations. Fundamental to all program evaluations is the validity of the causal attribution – that is, whether the program activities can be assumed to “cause” the outcomes that are found. This issue is well exemplified by Lipsey’s (1988, 18) study of a random sample of evaluation research published over a three-year period and drawn from three different referencing indices, a study that still reflects the reality of some program evaluation today. Of the 168 identified

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evaluation studies, 122 used a quantitative experimental or quasiexperimental design and were included in Lipsey’s systematic coding and appraisal of the quality of the research. He found the following conceptual, methodological, and statistical problems: 1 Causal complexity: 77 percent of the treatment evaluations were causally complex (multidimensional and applied over time), requiring differentiated causal constructs, but 84 percent of the studies handled the independent variable as a categorical dichotomy. 2 A lack of theory: 69 percent were non- or sub-theoretical, lacking a conceptual theory or model of how the program was to work. 3 A lack of information on dimensions of treatment implementation: less than 50 percent made any mention of the amount of treatment delivered; less than 33 percent mentioned treatment doses, duration, components, and so on. 4 An inability to replicate the program: not enough detail was provided concerning the program. 5 An inability to know what program components worked: there was a lack of differentiated program constructs. 6 A lack of information on measures: only 30 percent mentioned reliability, 19 percent mentioned validity, and 12 percent mentioned sensitivity. 7 A narrow statistical approach: with only rare exceptions, conclusions were based “almost entirely upon statistical significance testing against the thoroughly institutionalized p < .05 criterion.” Lipsey (1988, 22) concluded: “What this review reveals is that evaluation research in the experimental paradigm is based on constructs that substantially under-represent the complexity of the causal process at issue, is theoretically impoverished, is crudely operationalized, and in its results, is insensitive to genuine treatment effects and unreliable in its conclusions.” Lipsey’s focus reflects the conceptual, methodological, and statistical problems inherent in a number of outcome program evaluations, including mental health services evaluations, which can affect causal attribution. These problems evolved from a policy space where programs, services, and policies were developed, possibly based on theories but often guided by personal ideology, assumptions, opinion polls, and the “fad of the moment” (Stame 2004). Evaluators followed suit, guided by a positivist epistemology where theoretical

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frameworks were not developed; rather a “black-box” or “methodsdriven” approach was taken (Stame 2004). This approach was used to describe evaluations that examined an outcome (normally one outcome, at that) in relation to an intervention, and a causal link or attribution was assumed between the intervention and the outcome (Bickman 2000; Bishop and Vingilis 2006; Chen 1990, 2005; Cordray 1989; Cousins and Earl 1992; Koepsell et al. 1992; Lipsey 1988; Lipsey and Cordray 2000; Posavac and Carey 2003; Reynolds 1998; Sidani and Braden 1997; Stame 2004; Vingilis and Burkell 1996; Vingilis and Pederson 2001). Thus, the focus of evaluation was all on methods, with the randomized controlled trial (RCT) or randomized experimental design as the gold standard for evaluation methodology. Yet over the years, it has been the causal link between intervention and outcome that has come under scrutiny, even within experimental paradigms (Chen and Rossi 1983; Cordray 1989; Hohmann and Shear 2002; Koepsell et al. 1992; Lipsey 1988; Lipsey and Cordray 2000; Mayne 2001; Posavac and Carey 2003; Stame 2004; Vingilis and Pederson 2001). Programs, services, and policies are based on the validity of underlying assumptions about how and why they are supposed to work (Bickman 1996; Bishop and Vingilis 2006; Chen 2003, 2005; Grembowski 2001; Lipsey 1988, 1993; Reynolds 1998; Stame 2004; Weiss 1998). These underlying assumptions can be classified into two types: the program’s theory of cause and effect (also known as its program theory or change model) and the program’s theory of implementation (also known as its change theory, implementation theory, or action model) (Bishop and Vingilis 2006; Chen and Rossi 1983; Chen 1990, 2003, 2005; Grembowski 2001; Rimer and Glanz 2005; Weiss 1998). The program’s theory of cause and effect should conceptualize the underlying logic of how and why a program could “cause” specific outcomes (Bishop and Vingilis 2006; Grembowski 2001; Reynolds 1998; Weiss 1998; W.K. Kellogg Foundation 2001). It also overlaps with the National Cancer Institute’s (Rimer and Glanz 2005) concept of explanatory theory or theory of the problem, which expounds on the theory behind how and why the problem to be tackled exists. Unfortunately, answering this seemingly simple question of how and why a program should work can often be a challenge because most programs are causally complex. That is, the causal processes involved in conceptualizing how a program should work may include many components that extend over different periods (Lipsey 1988). Thus,

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unless a program offers a one-shot, one-time intervention, such as an inoculation, it is safe to say that in most cases programs, services, and policies, particularly in the community mental health arena, include causal processes that “may involve long chains of cascading direct and indirect effects, may be influenced by various extraneous events (i.e., be context dependent), and may have results that are delayed, diffuse, and subtle” (Lipsey 1988, 8). The crux of the problem with outcome evaluations conducted on these types of programs is that they often tend to ignore the program’s theory of cause and effect and the program’s causal complexity. That is, the conceptualization of how and why a program should work is not articulated by the program developer or the evaluator. The program’s theory of implementation identifies the theoretical basis for the strategy chosen to tackle the problem and also focuses on whether the program is actually implemented as intended (Bishop and Vingilis 2006; Chen 1990; Grembowski 2001; Weiss 1998). Commonly called process, progress, implementation, monitoring, fidelity, or formative evaluation, it examines both the program’s delivery and its coverage (Cousins et al. 2004; Isaac and Michael 1997; Posavac and Carey 2003; Rossi and Freeman 1993; Weiss 1998). Black-box evaluations typically also ignore this type of evaluation, even though it is considered fundamental to all evaluations in order to assess what the program actually does (Cousins and Earle 1992; Dewa et al. 2001; Sidani and Sechrest 1999). The assumption that programs, services, and policies are being delivered in accordance with objectives and as intended has been shown to be unwarranted (Rossi and Freeman 1993; Weiss 1998). Without an examination of program delivery, it will be difficult to explain why hypothesized outcomes were not found, and it will not be clear whether the lack of positive outcomes resulted from a poor theory of cause and effect, that is, from faulty logic concerning how and why the program should work, or from poor implementation of the program (Bickman 1987; Chen and Rossi 1983; Cousins et al. 2004; Vingilis and Pederson 2001). A commonly prescribed method for conceptualizing the theories of cause and effect and implementation is through the development of a causal pathway or model (also called an attribution model or a link model) from which a program-logic model is also developed (Bishop and Vingilis 2006; Bryant and Bickman 1996; Chen 2005; Cooksy et al. 2001; Grembowski 2001; Julian 1997; Julian et al.

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1995; Kaplan and Garrett 2005; Mayne 2001; McDavid and Hawthorn 2005; Posavac and Carey 2003; Rogers 2000; Sidani and Sechrest 1999). In fact, currently many granting agencies in Canada, the United States, and elsewhere now require developed logic models as part of the grant application process (Kaplan and Garrett 2005). Although the terms causal model and logic model have been used interchangeably in the literature, they reflect different, although overlapping, constructs (Chen 2005; Grembowski 2001). The causal model represents a series of boxes or steps of causal assumptions along a continuum that reflects the cause-and-effect theory underlying the program. The causal model focuses on the recipient of the program and reflects the process of change as a causal pathway that is assumed to occur with the person or the system (if the system is the recipient of the program). The program-logic model, on the other hand, represents the program activities, objectives, and short and longer outcomes that are expected to occur to change each of the boxes or steps of the recipient’s causal model. A simple example of a causal model, presented for heuristic purposes only and based on some neurobiological theory, could be as follows: headache take pain killer headache cured less grouchy. Note that the causal model reflects the causal pathway experienced by the recipient. A neurobiological cause-and-effect theory to explain how and why the recipient got a headache would form the actual basis of this model. The intervention, to “cause” positive outcomes in the recipient, should be based on evidence-based methods (a theory of implementation) in order to assess the headache properly and to provide the correct intervention, in this case, pain killers. The logic model would be based on the chosen implementation theory, with activities and objectives focussing on proper assessment of the headache and the provision of correct pain killers. The short- and longer-term outcomes would be the same. Obviously, different theories of cause and effect and implementation could inform the causal and logic models that one develops, and clearly, the causal and logic models overlap. But they do reflect different foci: the causal model represents the causal pathway of change hypothesized to occur within the recipient of the intervention, and the logic model represents the activities and objectives of the program that is to tackle the steps of the causal pathway. The more steps that are hypothesized to explain the causal pathway(s) to change, that is, the greater the casual complexity, the more activities an intervention

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should have to tackle the steps of the causal model. Yet even though many evaluation scholars over the last two decades have argued for the importance of using theory and causal or logic models in mental health services evaluation (e.g., Bickman et al. 1992; Julian et al. 1995; Lipsey 1993; Yampolskaya et al. 2004), actual practice is limited. For example, Cosden and colleagues (2003) conducted an evaluation of a mental health treatment court with Assertive Community Treatment (act). Using an experimental design with a treatment-asusual control condition, they hypothesized that clients participating in the mental health treatment court should exhibit more pre-post life satisfaction, greater reduction in psychological distress, more extensive change in their global independent functioning, and more improvement in their alcohol and drug problems. No information was provided on exactly what the clients in the experimental and control groups were actually receiving (i.e.,there was no process evaluation). Nowhere did they articulate how and why the mental health treatment courts would lead to the hypothesized improvements. That is, no model was presented to explain why the various components of the mental health treatment court should lead to the hypothesized changes, and indeed the results found that clients in both the mental health treatment court and the treatment-as-usual condition showed improvement. The authors were left trying to speculate on these outcomes by suggesting that the control group “felt that they were getting special treatment by virtue of being part of the project” (Cosden et al. 2003, 425). If simply being part of a study can have positive effects on persons with mental illness, then policy-makers may want to revisit what they offer in their programs. Clearly, this study offers limited information for researchers, program developers, and policy-makers. Thus, to date in community mental health services evaluations there is still limited evidence of the explicit use and articulation of cause and effect theories and causal and/or logic models for framing interventions and evaluations (Foy et al. 2007; Styron et al. 2006), although evaluations are now more likely to involve collecting process data (fidelity measures) to assess the implementation of the intervention (Orwin 2000). For example, ACT programs have been one of the most widely evaluated of all community mental health services (e.g., Allness 1997; Bond et al. 1988, 418; Bond et al. 1990; Bond et al. 1995; Bond et al. 2001; Marx et al. 1973; McGrew and Bond 1995; Morse et al. 1997; Scott and Dixon 1995; Stein et al. 1975;

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Stein 1980; Test and Stein 1978; Thompson et al. 1990; Wilson et al. 1995); yet, as in the example above, most are noteworthy in their black-box approach to evaluation (Bishop and Vingilis 2006; Cousins et al. 1992; Dewa et al. 2001; Franx et al. 2008; Mechanic 1996; and see Bishop et al., chapter 12, this volume). Some examples of different types of community mental health services evaluations that have articulated their use of both theory and/or logic models and process evaluation include Bickman’s (1996, 1997) Fort Bragg Demonstration Project evaluation of mental health and substance abuse services for children and adolescents; Carpenter and colleagues’ (2007) evaluation of psychosocial intervention in mental health; Forchuk and colleagues’ (2005) evaluation of the effectiveness of a transitional discharge model of care from psychiatric hospital to community; Henggeler and colleagues’ (1992) evaluation of multi-systemic therapy delivered through a community mental health centre; and Vingilis, Hartford, and colleagues’ (2007) evaluation of an emergency department intervention for persons with mental health concerns, to name a few. These examples, using experimental or quasi-experimental multi-methods designs, also exemplify the causal complexity of interventions and thus the complexity of methods and measures that has become standard in program evaluation methodology.

Methodological Issues in Program Evaluation Causal complexity relates to another real challenge for the outcome evaluation of community mental health services. Two types of outcome evaluations are efficacy and effectiveness trials. Mental health service and psychotherapy studies under tightly controlled “laboratory” conditions (efficacy trials) have not been replicated in field or community service settings (effectiveness trials) (Speer 1998). Yet as Speer stated, “The problem is not that community-based services have been shown to be ineffective. The problem is that until recently there has been little effort to even examine the question” (4). The messiness of the real world of community mental health services has challenges associated with outcome evaluation, as the interventions are by nature non-standardized and highly dependent on macro-, meso-, and micro-environmental influences, as well as on personal preferences and relationship dynamics (Bishop and Vingilis 2006; Wolff and Pogorzelski 2005). Consequently, effectiveness evaluations

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have lagged behind efficacy evaluations, not only because of the theoretical complexity of the interventions but also because of the methodological polarization that has occurred regarding appropriate research designs. Despite the shared conceptualization and methodology that have evolved in program evaluation, a debate still continues in some quarters on appropriate quantitative design and methods for evaluating community mental health services outcomes, a debate that has nearly paralyzed systematic efforts to conduct mental health services evaluations in community settings (Fonagy 1999; Speer 1998). Early mental health services evaluations focused on applying laboratory and experimental research designs, often RCT methodology, although they were soon identified as not feasible for various ethical, fiscal, conceptual, and methodological reasons (Fonagy 1999; Hohmann and Shear 2002; Speer 1998; see also Forchuk’s chapter 10, this volume). Biglan et al. (2000) list a number of limitations of RCT s. They include the high financial cost of the large sample sizes needed in such studies, the challenge in developing generalizable theoretical principles regarding community change processes, the obscuring of unique relationships within and among communities, and the problem of contamination between the intervention and control communities because of diffusion of intervention activities. However, an RCT is still considered by some as the only method to use for health services outcome evaluations. For example, in his Cochrane lecture McPherson (1994, 6) argued that “since randomisation alone eliminates the selection effect of therapeutic decision making, anything short of randomisation to attribute cause to consequent outcome is a waste of time.” Yet other scholars have critiqued the RCT precisely because the testing of theory and the valid attribution of causation are not guaranteed with RCT s (e.g., Barnes et al. 1999; Biglan et al. 2000; Burtless 1995; Fonagy 1999; Hohmann and Shear 2002; Lipsey and Cordray 2000; Persons and Silberschatz 1998; Tones 1997; Wandersman 2003). As Koepsell and colleagues (1992, 33) have written: The randomized controlled trial has become a widely accepted paradigm for evaluating the effect of health interventions, against which nonexperimental methods are judged and often found wanting. The design and the size of most randomized trials are usually driven by a primary research question,

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which typically concerns the effect of an intervention on final outcomes. Unfortunately, this focus on outcomes may result in overlooking the need to characterize both the intervention itself and the causal mechanisms by which it is supposed to work. Interventions then become “black boxes” whose overall effects may be detectable, but whose contents are obscure. Nor are the results necessarily useful to mental health care practitioners. There are major differences between clients seen in research settings and those seen in regular community mental health care settings, and the kinds of interventions carried out are also quite different (Catty et al. 2002; Fonagy 1999; Hohmann and Shear 2002; Persons and Silberschatz 1998; Speer 1999). As Green (2001, 167) challenged: “Where did the field get the idea that evidence of an intervention’s efficacy from carefully controlled trials could be generalized as the ‘best practice’ for widely varied populations and situations?” Thus, although current evaluation scholars support the use of the most rigorous methodology possible in the community mental health service setting, many evaluators have questioned the “slavish devotion to the randomized experimental model in evaluating the effectiveness of mental health services” (Speer 1998, 14). This reality then challenges the “evidence-based” health care mantra that lists RCT s on top of “a hierarchy of strength of evidence for treatment decisions” (Guyatt et al. 2000). But it also provides fodder for health care funding agencies to decide not to fund interventions that have not undergone RCT s (Druss 2005, 92; Fonagy 1999; Speer and Newman 1996). Part of the polarization has been related to the tension between efficacy and effectiveness evaluations and thus between internal and external validity, in which evaluation methods for interventions in controlled laboratory conditions are presumed to be appropriate for interventions practised in community settings (Hoagwood et al. 2001; Speer 1998, 1999). The methods used for efficacy trials have followed the classic experimental paradigm in which protocols, manuals, and so on, are totally standardized; they are given for a fixed number of sessions by highly trained clinicians who must provide the same intervention, in the same way to every client. There is independent assessment of clinician adherence to the protocol, and all clients are a volunteer, randomly assigned, homogeneous group under rigid inclusion and exclusion criteria; they often have no other

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challenges but the condition for which treatment is sought (Speer 1998). This highly controlled method may explain why the benefits of efficacy trials of mental health services in controlled RCT s are small to negligible when assessed in effectiveness trials using RCT methodology (Barnes et al. 1999). Wolff and Pogorzelski (2005) argue that such specificity and stability of participants and interventions should also be the two foundations on which effectiveness evaluation is based. The nature of the intervention must be clearly defined and stable, since social, structural, and/or procedural changes can alter an intervention, and thus effectiveness (Belenko 2002; Wolff and Pogorzelski 2005). Yet in the real world, community mental health services can be a “moving target,” constantly changing and evolving (Belenko 2002). Many community mental health services can be inherently unstable, adapting as they are being implemented for numerous client and/or environmental reasons (Belenko 2002; Castro et al. 2004; Wolff and Pogorzelski 2005). As a consequence, a large array of time-varying measures – specifically, measures of three types of change – need to be collected: measures of (1) environmental change, (2) intervention and implementation change, and (3) change in outcome (Bishop and Vingilis 2006; Wolff and Pogorzelski 2005). Moreover, because of the time-varying measures, advanced statistical methods, such as multi-level modelling (to be discussed later), need to be considered (Bishop and Vingilis 2006). The most rigorous, quantitative outcome evaluation methodology used in community mental health services if random assignment has not been possible has been that of quasi-experimental methods (e.g., Cook and Campbell 1979), which some have decried as “a waste of time” (e.g., McPherson 1994). Shadish and Cook (2009), in a seminal article, reviewed recent advances in addressing key issues related to experimental and quasi-experimental methods and provided empirical evidence on the conditions in which various quasiexperimental designs “might provide effect estimates comparable to randomized designs.” Yet of the three quasi-experimental designs discussed by Shadish and Cook (2009) and standard evaluation textbooks (e.g., Grembowski 2001; Posavac and Carey 2003; Rossi et al. 1999), only non-equivalent comparison group (prospectivecohort and case-control) designs have been used extensively in community mental health services evaluations, although other designs, such as regression discontinuity designs (RDD s) and interrupted time

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series (ITS) designs, have been shown to suffer from fewer threats to internal validity (Cook and Campbell 1979; Grembowski 2001; Posavac and Carey 2003; Rossi et al. 1999). Regression discontinuity designs (also called cut-off-based designs) have a cut-point, or threshold, where people above the threshold receive the intervention, while people below do not (the comparison group) (Grembowski 2001; Posavac and Carey 2003; Rossi et al. 1999; Shadish and Cook 2009). A regression is fit to predict outcome based on assignment, with a dummy variable used to reflect the cut-point. If a statistically significant change in slope or level (discontinuity) is found between the intervention and comparison groups, an effect can be inferred (Grembowski 2001; Posavac and Carey 2003; Rossi and Freeman et al. 1999; Shadish and Cook 2009). Various studies have shown that the regression discontinuity at the cut-point is an unbiased effect estimate when correct analysis is used (Shadish and Cook 2009). Moreover, analytic advances to tackle nonlinearities and treatment misallocations have recently been made (Shadish and Cook 2009). Yet no examples have been found of community mental health services evaluations using this design. Given that cut-off scores or thresholds have been used in mental health services to determine who receives an intervention and who does not, regression discontinuity could be a useful design for estimating causal effects (Cook 2008; Shadish and Cook 2009). A second commonly described method for evaluation involves interrupted time series designs in which a large number of observations (e.g., 60+ time points), such as the number of hospitalizations per month, are needed to statistically model trends (e.g., seasonality) and autocorrelations (Biglan et al. 2000; Grembowski 2001; Isaac and Michael 1997; Mertens 2005; Posavac and Carey 2003; Rossi et al. 1999; Shadish and Cook 2009; Weiss 1998). Here too an effect is inferred as a change in slope or level at the point where the intervention was introduced. Moreover, various non-linear changes in slope or level can be modelled with the analyses, since changes can be abrupt or gradual, linear or non-linear (Grembowski 2001). Shadish and Cook (2009) have also described the strength of short time series designs, such as ABAB designs (treatment, no treatment, treatment, no treatment), that can be particularly useful with clinical populations. Time series statistical methods and newer analytic models with the use of pooled time series and multi-level models (Duncan and Duncan 2004), particularly with comparison

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time series, can be feasible and useful, and they can suffer from fewer internal validity threats than non-equivalent comparison group studies (Grembowski 2001; Isaac and Michael 1997; Mertens 2005; Posavac and Carey 2003). One of the challenges with the use of time series analysis has been to determine what length of time series (how many time points) are needed to obtain enough statistical power for accurate causal estimates (Shadish and Cook 2009). However, recently McLeod and Vingilis (2005; 2008) have developed a methodology for computing a power function for pulse, step, and ramp interventions with autoregressive integrated moving-average models (ARIMA) and fractional errors so that sample size determination can be made for time series intervention analyses. Yet despite the methodological strength of interrupted time series designs for program evaluation (Biglan et al. 2000; Duncan and Duncan 2004; Vingilis and Pederson 2001) and the role they have played in clinical-psychology, education, economic, road safety, and health promotion intervention evaluations, the use of time series research designs in community mental health services is exceedingly limited (e.g., Hough and O’Brien 2005). Non-equivalent comparison group designs, the “workhorse design for causal inference” (Shadish and Cook 1999, 2009) in community mental health outcome evaluations, have greater challenges. They may suffer from potential internal validity threats, such as selection bias in which intervention effects can be confounded because the experimental population may be systematically different from the comparison population in ways that may be related to outcome (Richards et al. 2007; Salkever et al. 2004; Shadish and Cook 1999, 2009). In recent years, advances in design and statistical advances have addressed these threats (Shadish and Cook 2009). With quasiexperimental designs, Shadish and Cook (609) have recommended that comparison groups be locally and focally similar, that is, “in the same locale as the treatment group and focused on persons with the same kinds of characteristics as those in the treatment group, most particularly the characteristics that are most highly correlated with selection into conditions and with the outcome under investigation.” Equivalency of the comparison group can also be increased with the selection of a group that is matched on “stable covariates, especially pre-test measures of outcome variables” (610). Recent statistical methods of reducing biased estimates of non-experimental studies will be further described in the statistical section below.

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Other types of research designs (both quantitative and qualitative) are being used more frequently in community mental health services evaluations, albeit more commonly for process than for outcome evaluations. For example, participatory action research, case study, and focus group designs are increasingly being used to provide critical information for and understanding of program development, implementation, and outcomes (Barnes et al. 2006; Coristine et al. 2007; Cousins and Earl 1992; Jacobson and Curtis 2000; Lord et al. 1998; Nelson et al. 1998, 2001; Wynaden et al. 2003). In a paper entitled “Nothing about me, Nothing without me,” Nelson and colleagues (1998, 906–7) have provided various recommendations to promote values of empowerment, supportive relationships, social change, and learning through participatory action research with psychiatric consumer/survivor organizations. Additionally, the concern over escalating health care expenditures has spawned a surge of economic evaluations in community mental health services (Evers et al. 1997; Guthrie et al. 1999; Hoch and Dewa 2005; Latimer 1999, 2005). However, Evers and colleagues (1997) and, more recently, Romeo and colleagues (2005), in their reviews of economic evaluations of mental health care interventions, concluded that few good quality, full economic evaluations have been conducted: quality has been limited by sample size, measurement of costs, and statistical and econometric issues. Other notable methodological issues in the evaluation of community mental health services relate to measurement. The first general one would seem straightforward: measure what you are trying to change. But straightforward it is not. It is critical that the chosen process and outcome measures be directly related to the theory of how and why changes are to occur (Bishop and Vingilis 2006). For each box of the theory-based causal model of the intervention to be evaluated, the question, “Did it happen?” is the key one to answer. Subsequently, answering the question, “How will I know if it happened?” should provide the clues on what to measure. Then the specific choice of measures would be predicated on the availability of the most reliable, valid, and sensitive measures. Yet it is not unusual to read a list of measures in an evaluation study with no attempt having been made to explain how the various measures are hypothesized to hang together theoretically or to interact with each other and to explain how the different patterns of measures are to be interpreted (Bishop and Vingilis 2006). Moreover, a recent trend

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in health services research, including mental health services research, has moved this idea of lists of measures further by attempting to develop “indicators” of positive outcomes for various health services. For example, the Ministry of Health in Ontario, Canada, has mandated mental health reporting using a data collection system of over three hundred indicators for all hospitals with adult in-patient mental health beds. Evaluation and thus interpretation of trends, patterns, and relationships can be difficult without an overall theoretical framework by which to understand how and why persons with mental health concerns recover (Bishop and Vingilis 2006). Other fundamental issues of research methodology are related to operational definitions, construct, content, and other validities – critical for all research enterprises – that also need to be addressed in program evaluations (Lipsey 1988; Lipsey and Cordray 2000; Patrick and Chiang 2000). Numerous scholars have reviewed conceptual and methodological challenges in measurement of health and other outcomes and in the measurement of independent variables (Barnes et al. 1999; Chamberlain and Rapp 1991; Patrick and Chiang 2000; Wolff and Pogorzelski 2005). Evaluators should have a clear understanding and description of terms, such as community health teams, usual or standard care, and so on, but the terms are often not operationally defined in detail (Catty et al. 2002). Services from different years or from the same or different communities have been found to contain different components, even if the same label has been used (Catty and Burns et al. 2002). In addition, early research on mental health services was criticized for using one outcome measure or outcome measures that had not been strongly associated with client symptoms (Burns 2007; Chamberlain and Rapp 1991; Speer 1998). Hospitalization and days of stay are two such problematic measures, although they are still commonly used in evaluations (Bishop and Vingilis 2006; Catty et al. 2002; Chamberlain and Rapp 1991). Current thinking reflects the belief that one measure cannot capture the multiple aspects of human functioning (Burns 2007): “consumers are inclined to improve in some aspects, to not change in others, and occasionally become worse on other dimensions of adjustment and functioning” (Speer 1998, 48). Moreover, many measures vary with time. Some, such as psychiatric symptoms, are not stable and therefore need to be measured over the course of a study.

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Scholars have proposed that at least three groups of stakeholders should be considered for their perspectives on client outcomes: (1) the client/consumer, since he/she is clearly the best judge of his/her own distress, functioning, and so on; (2) the community (family, neighbours, employers, and so on) and (3) the mental health practitioner(s) providing the services (Allen and Carpenter et al. 2003; Bishop and Vingilis 2006; Nelson et al. 2001; Simpson and O’House 2002; Speer 1998), although parsimony is critical, and the measures chosen should be directly related to the theoretical framework of how and why the client/consumer should recover. Notably, greater client/consumer involvement in the entire evaluation enterprise is becoming more evident in various studies (Forchuk et al. 1998; Forchuk et al. 2005; Nelson et al. 2001; Simpson and O’House 2002).

Statistical Issues in Program Evaluation Community mental health services are complex, changing entities whose clients are similarly complex and changing over time. Additionally, community mental health services are hierarchical structures whereby clients are nested within services that are nested within regions, and so on. Statistical analysis of hierarchical data, which includes longitudinal data, necessitates advanced statistical modelling methods (Bishop and Vingilis 2006; Boyle and Willms 2001; Brekke et al. 1997; Bryk and Raudenbush 1987; Gibbons 2000; Kenny et al. 2004; Lipsey and Cordray 2000; Snijders and Bosker 1999). However, Gibbons (2000, 91) observed: “Despite recent advances in statistical methods for longitudinal research, the cost of mental health services research is not always commensurate with the quality of the analyses which often consist of little more than a correlation of variables measured at various times, or group means plotted at successive time points.” Although longitudinal and nested data are common to community mental health services evaluation, they have been a challenge for researchers in the conduct of statistical analyses because of repeated (intra-individual) measures collected on the same individual (Gibbons 2000, 91). Historical approaches have generally used baseline and post-intervention data and computed a change score that led to the loss of important information (Gibbons 2000, 91; Lambert et al.). Participant loss also occurred when end-point analysis was conducted to eliminate participants who might have missed

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one or more follow-up measures (Gibbons 2000, 91). Other statistical methods include one-way ANOVA s, used at each follow-up time point, which would cause multiple-comparison problems, and timedependent Cox-modelling, random-effects regression and generalized estimating-equation (GEE) regression, which could give biased effect estimates, since they do not adjust for the effects of outcomes on covariates or for the effects of earlier outcomes on later outcomes (Robins et al. 1999a, 1999b; Rothman and Greenland 1998; Schildcrout and Heagerty 2005). Additionally, some studies include only study completers, which leads to internal and external validity problems. Over the past thirty years, the continuous development and refinement of statistical techniques has fundamentally revised how evaluators should conceptualize the assessment of change in the outcome evaluation of an intervention. Standard pre-post models with two waves are not uncommon. For example, Davis and Spurr (1998) evaluated a community child mental health service by using the Mann-Whitney test to compare the intervention and control groups on all variables at pre-intervention and in relation to their pre-post change scores and by using the Wilcoxon Signed Rank test to conduct within-group comparisons of pre-post assessments. However, various scholars have argued that two-wave, pre-post experimental or quasi-experimental designs are problematic for studying change (Lambert et al. 2001; Singer and Willett 1996; Willett et al. 1998). As Lambert and colleagues (2001) stated: “When only pre-post data are available, difference scores, repeated measures analysis of variance, residual gain scores, and analysis of covariance may lead to confused inferences based on insufficient evidence.” This is because change, whether it is in functioning, skills, attitudes, and so forth, occurs continuously over time, and a simple two-data point, pre-post comparison cannot capture the features of that trajectory (Willett et al. 1998). Regression to the mean is also posited by many scholars as a challenge with the use of only pre-post data points and attempts to adjust or correct for regression to the mean have also met with challenges (Speer 1999). Thus, currently many scholars advocate that change should be measured from a longitudinal perspective with multiple waves of data collected (Lambert et al. 2001; Singer and Willett 1996; Speer 1999; Willett et al. 1998). Multi-level modelling (also known as hierarchical linear modelling or mixed modelling) provides an extremely useful approach to

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the analysis of multiple waves of data. Multi-level modelling allows for the analysis of non-independent or hierarchical data that arise when studying topics such as clients nested within therapists, PACT teams nested within community mental health services, or longitudinal repeated measures nested within individuals. Traditional general linear models are not well suited for the analysis of these types of data, given the violation of the assumption of independence. In contrast, multi-level models are explicitly designed to analyze hierarchical data structures and can incorporate individual-level predictors, group-level predictors, and individual-by-group-level interactions. As Gibbons (2000, 91) noted, “These [multi-level] models are critical to mental health services research in that they provide statistically rigorous approaches to both the definition and analysis of outcome which is invariably multi-dimensional and based on qualitative factors.” A particularly flexible statistical methodology, multi-level modelling can incorporate different data collection schedules, a differential number of waves, experimental or observational designs, and single (individuals-only) level or multi-level (e.g., clients nested within clinics) designs. Further it can identify temporal data patterns and include time-varying predictors and interactions with time (Graham 2008). For example, growth-curve modelling allows for the assessment of intra-individual level and inter-individual level differences in change (Bishop and Vingilis 2006; Boyle and Willms 2001; Brekke et al. 1997; Bryk and Raudenbush 1987; Gibbons 2000; Kenny et al. 2004; Lipsey and Cordray 2000; Snijders and Bosker 1999). Individual change across time is modelled and subsequently the effects of covariates (mediators and moderators) are examined to determine whether there are systematic differences in rate or type of change (Kenny et al. 2004; Snijders and Bosker 1999). Thus, this method can be useful in mental health services evaluations to model person-specific trends where treatment responses can be quite individualized (Gibbons 2000). Yet despite the availability of these statistical advances in multilevel modelling, with few notable exceptions, these methods are not commonly found in community mental health services evaluations. Some examples of notable exceptions include studies by Aseltine and DeMartino (2004), who examined the effectiveness of the Signs of Suicide prevention program; Hobbs et al. (2000), who examined the impact of de-institutionalization on client outcomes of long-term clients transferred to community residences in Sydney, Australia;

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Kenny et al. (2004), who used and expanded multi-level methods to estimate treatment effects and mediators and moderators of ACT in a randomized longitudinal experiment; and Bishop and Vingilis (2006), who are testing a framework for comprehensive evaluation of client outcomes in community mental health services. Other statistical methods have been developed to adjust quasiexperimental results to better approximate results from experimental designs. Methods used to control for selection bias have included propensity score analysis (Dehejia and Wahba 2002; Salkever et al. 2004; Snow Jones et al. 2004; Stürmer et al. 2006) and multipleregression methods, although Salkever and colleagues (2004) and Shadish and Cook (2009) suggest that the “[s]trong ignorability assumption” would need to be met, which would require the measurement of all covariates associated with treatment and outcome (Shadish and Cook 2009). Shadish et al. (2008), in a study in which they randomly assigned participants to either a random-assignment arm or a non-random-assignment arm, were able to reproduce very similar results between the quasi-experiment and the experiment with the use of different propensity scores, calculated from a large list of pre-test covariates. However, a propensity score based on weak predictors, such as age and sex and ethnic and socioeconomic status, not only did not decrease bias, it sometimes even increased it. These and other adjustment methods, such as the instrumental variable methods, have been used more frequently by mental health economists (Crown et al. 1998; Lu 1999; Salkever et al. 2004), although still not commonly by other program evaluators in community mental health services.

Conclusions In summary, the good news is that in the past decade, community mental health services program evaluation has expanded to include both quantitative and/or qualitative methods and a variety of designs and types of evaluations, such as participatory action research, process evaluations, and economic evaluations, in addition to outcome evaluations. Moreover, there has been an explosion of publications that have conducted process evaluations, that is, that have examined program implementation, in addition to conducting development evaluations in which the development of theories for programs, evaluation, and statistical methods and measurement

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issues have been articulated (e.g., Cooksy et al. 2001; Cousins et al. 2004; Foy et al. 2007; Julian 1997; Kaplan and Garrett 2005; Lord et al. 1998; Shadish and Cook 2009; Vingilis and Fuhrman 2007; Vingilis, Paquette-Warren et al. 2007; Yampolskaya et al. 2004). For example, Cousins and colleagues (2004) have introduced the “key components profiles” (KCP) method as an alternative for implementation evaluation; they validated it in the context of an intensive case management program for homeless clients with severe mental illness. These studies can educate potential evaluators on various current conceptual, methodological, and statistical approaches that can be used for community mental health services evaluations. Additionally, more community mental health services evaluations have included theories of cause and effect and implementation and have conducted process evaluations (Bickman 2000; Holden et al. 2001). For example, Carpenter and colleagues (2007) described a “stepwise approach” to the evaluation of a training program for community mental health practitioners. Their cause and effect theory, based on a previously established framework and systematic literature reviews, articulated a causal model to explain the processes of change to affect the outcomes of the service users and trainees. They also focussed on evaluating the training to assess whether it was delivered according to specification, based on their theory of implementation. Unfortunately, recently published outcomes evaluations of community mental health services can still be found that have not identified a theoretical framework and have not additionally conducted a process evaluation. Without the articulation and measurement of a program’s theoretical framework, the study becomes black-box or methods-driven research that can make it a challenge for policy-makers to understand how and why an intervention works and to identify the key elements for successful implementation (Chen 1990; Chen 2005; Lipsey 1988; Posavac and Carey 2003; Stame 2004; Vingilis and Pederson 2001). This has been a key criticism of ACT, for example, where policy-makers have been implementing it in their locales in different ways without knowing what components are and are not necessary for client recovery (Bishop and Vingilis 2006; Cousins et al. 2004; Dewa et al. 2001; Franx et al. 2008; Mechanic 1996; also see this volume, chapter 12). The methodology debate for outcomes evaluation continues. Both the strengths and limitations of RCT s have been amply discussed by many scholars (e.g., Barnes et al. 1999; Biglan et al. 2000; Burtless

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1995; Fonagy 1999; Koepsell et al. 1992; Lipsey and Cordray 2000; Persons and Silberschatz 1998; Speer 1998, 1999; Tones 1997; Wandersman 2003). Quasi-experimental designs, notably nonequivalent comparison group designs, have been commonly used for outcomes evaluations in community mental health services, but curiously, the two stronger quasi-experimental designs, regression discontinuity and interrupted time series designs, are noteworthy by their absence. Yet the use of cut-offs or thresholds and the use of administrative time series outcome data, such as monthly rates, are common to community mental health services, making regression discontinuity and interrupted time series designs appropriate ones to use. A similar pattern is noted with the statistical procedures that are commonly used in community mental health services research. Statistical advances of the past two decades have brought to evaluationresearchers multi-level modelling and other techniques to provide a flexible statistical methodology for evaluating changes and to adjust quasi-experimental results to better approximate results from experimental designs. Yet these methods are also not very visible in published community mental health services evaluations. In summary, evaluation methodology is a very complex science. It is also a unique science. Research methods learned in other disciplines cannot automatically be applied to the conduct of program evaluations. Conceptual, methodological, and statistical approaches are constantly advancing to improve the ways in which interventions can be evaluated. Yet the various methods and approaches are moot if limited resources are available to conduct evaluations of community mental health services, although again the good news is that some jurisdictions, such as Ontario, Canada, are supporting various evaluative initiatives of its community mental health services (e.g., CMHEI 2004; SEEI Coordinating Centre 2009). This resource problem may be responsible for the limited number of evaluations in the area. Programming resources from different public and private sectors rarely provide substantive funds for evaluations, and often community agencies do not have the skill sets to conduct the evaluations. Additional challenges in real-world research include problems with data linkages among agencies and organizations, leading to the inability to follow consumers through their use of various community mental health services. Moreover, as noted in this review, the evaluation of community mental health services is a highly complex endeavour. For these reasons few community mental health services

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evaluations are actually available for the numbers of programs and services that are running. Yet there is a need to know what works and why. Because of the high burden of mental illness, it behoves society to fund and apply the unique and evolving program evaluation methodology in order to provide the best evidence possible to health care providers and patients/clients/consumers so that they are able to make more informed decisions about care.

4 Interfacing Hospital and Community Mental Health Services: The Role of the Emergency Department Beth Mitchell Hospitals have always played a significant role in the mental health system. Historically, they were the primary site of psychiatric care, which tended to be long-term, inpatient-based, and custodial in approach (see chapter 2, this volume). Hospitals were places of refuge, of protection, of assessment and diagnosis, and of treatment; they reflected the best – and at times, the worst – of interventions with individuals suffering from mental illness. As models of mental health care evolved and the emphasis on early intervention with mental illness and recovery in the community grew, hospitals were required to change and offer new services that focused on more short-term, ambulatory, and intensive-treatment programs. Legislation, policies, and funding have served as catalysts to ensure these changes. Across North America, Australia, England, and other parts of Europe, numerous reports have highlighted the benefits of care in the community for those suffering with mental illness, including opportunities for meaningful activity and work, social interaction and relationships, and less intrusive services (Thornicroft and Bebbington 1989; Simmonds et al. 2001). In the extreme, assumptions have been made that all mental health care could be delivered in the community and that hospital-based services were therefore considered at best minimally relevant and at worst intrusive and unhelpful (Prior 1991). Mental health reform throughout many jurisdictions has thus triggered the plan to move the majority of mental health services to the community and to reduce the role of hospitals as a mainstay of treatment. While the research is still limited, there is growing

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evidence that community-based crisis response is a viable alternative for emergency services in mental health (Compton et al. 2008). However, Thornicroft and Tansella (2004) emphasize the importance of a balanced approach in which community and hospital services operate in a stepped, sequenced model according to available resources. Even with additional community capacity, including crisis response, the data suggest that the use of emergency psychiatry services has remained relatively stable over time (Paradis et al. 2009). There is thus an ongoing need for the role of hospitals and, in particular, emergency psychiatric services to respond to and support consumers during times of crisis. Indeed, acute hospitals may have the most complex task of managing patients at their most critical stages (Dratcu 2002). This chapter will therefore focus on the unique role of hospital-based psychiatric emergency services within the more comprehensive system of care. As with the documents of other jurisdictions, the Ontario Ministry of Health’s framework paper (1999) articulated principles for reforming the mental health system affirming that consumers should be at the centre of the system with services tailored to their needs. Services should be streamlined, coordinated, and based on evidence, and there should be continued investments to protect and sustain programs. The framework outlines a specific continuum of needs that necessitate service availability across a well-functioning mental health system that is primarily community-based. However, consistent with the growing recognition of the role of hospitals, included in this array are acute-care hospitals, including crisis and emergency services. The range of supports and services are meant to incorporate crisis counselling, environmental stabilization, advocacy, assessment (including by a psychiatrist), and the initiation of treatment. Emergency mental health services offer opportunities for close observation, diagnosis, and management of acute distress and behavioural disruption, with immediate response to conditions. By integrating emergency psychiatry services into general hospitals, an attempt has been made to reduce stigma and discrimination (Happell et al. 2003), as well as to address the co-morbidity of physical and mental illnesses (Wynaden et al. 2003). If the mental health system, including the hospital and community agencies, is well-coordinated and responsive, the frequency of emergency department visits should be minimized, and the process

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should be relatively brief and discharge-focused. Ideally, clients and families would have access to regular support and treatment from community resources designed to meet their needs in time frames and locations that facilitate contact. Emergency department visits would thus focus on unexpected events created by unpredictable factors. Nevertheless, often the emergency department serves as a default for less than optimal community-based psychiatric services; indeed, studies have demonstrated that as the availability of community mental health services fluctuates, psychiatric emergency visits also vary (Catalano et al. 2003). Studies in Australia have revealed a tenfold increase in patients presenting in emergency departments with psychiatric problems when deinstitutionalization occurred without the concomitant development of community mental health services (Kalucy et al. 2005). Research has also shown that approximately 25 to 30 percent of emergency department mental health visits are non-emergent and could be redirected to less intensive and thus less costly system components (Claassen et al. 2000; Carpenter et al. 2005). Not only would these community services be more costeffective, but they would also be likely to produce less frustration and stress for clients and families. Hospital providers and researchers have attempted to establish criteria that identify the appropriateness of an emergency department visit for mental health reasons. However, there is no clear definition of “appropriate” use of emergency department psychiatric services. Often it is assumed that an emergency department presentation without a significant medical problem is inappropriate (Koziol-McLain et al. 2000), but this view diminishes the pain and suffering that can accompany psychiatric symptoms. The emergency department is in fact a logical alternative for those who feel significant distress or require immediate assistance with their symptoms; often those who go to the emergency department perceive that their needs require urgent attention, even when providers do not agree (Carpenter et al. 2005). Since many community agencies operate from nine to five, five days a week, clients must use other sources to support them during crises. A number of studies have indicated that clients say they go to the emergency department because they feel overwhelmed and have no place else to go (Clarke et al. 2006; Koziol-McLain et al. 2000). As well, family members and friends may rely on the emergency department for support and assistance if the individual with mental health problems is creating

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upset or risk for which they have no remedy (Clarke et al. 2007). Because of the problems of access to primary care or the lack of available community services to respond to crises, the emergency department is often the only remaining choice (Koziol-McLain et al. 2000). Patients report using a number of strategies to manage their psychiatric symptoms before coming to the emergency department; for example, many had contacted family or friends for support and/ or advice or had used alcohol or drugs to ameliorate their symptoms (Carpenter et al. 2005). McNiel and Binder (2005) have shown that the frequent use of emergency mental health services is particularly prevalent in certain populations, such as those who are homeless, those who have poor adherence to community treatment, and those who come in contact with the legal system. However, a particular challenge of an emergent mental health problem is that the psychiatric presentation often does not fit with the typical orientation of an emergency department and clients may experience at best callous and at worst negative or hostile responses during their visit. Clarke and colleagues (2006) have shown that mental health clients want certain basic provisions during their emergency department visit, including the use of advanced directives, more comfortable physical environments for waiting and treatment, increased peer support, better training of emergency personnel, and collaboration between themselves and the providers. However, emergency psychiatric visits rarely provide these services. The research regarding clients’ experiences in the emergency department suggests issues related to wait times, the attitudes of providers, and “diagnostic overshadowing,” where patients are treated or simply dismissed as “psychiatric” without validation of their physical symptoms. Other studies suggest that clients with psychiatric problems do in fact wait longer than others with medical conditions, in part because of the complexity of their issues but also because of the providers’ lack of expertise and confidence, along with their discrimination towards the psychiatric population in general (Clarke et al. 2007; Kahn 2001; Mazeh et al. 2003). In addition, clients may often have unrealistic expectations about what can be provided in an emergency psychiatry service – for instance, wanting family therapy or prescriptions for medication without proper assessment (Carpenter et al. 2005). If these individuals with somewhat unusual symptoms and erroneous expectations encounter emergency staff or physicians who are more comfortable dealing with trauma or

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life-threatening illnesses, it should be no surprise that there is often a “clash of cultures” (Happell et al. 2003). Nevertheless, the emergency department is still a necessary component of the mental health system. In the same way that no amount of health promotion or cardiac rehabilitation can eradicate the occurrence of heart attacks, no amount of community support and treatment can eliminate the need for emergency assistance at some point during the course of mental illness. Care in a community system does not prevent the use of emergency services; it may simply delay the presentation of serious symptoms (Claassen et al. 2005). The literature has shown that emergency psychiatric services are typically used by three groups: those referred by family physicians, those who were already receiving specialized psychiatric care in the community, and those who came from the broader community and were exhibiting high-risk behaviours (Spurrell et al. 2003). Indeed, the emergency department should be the component of the system that addresses emergent and/or crisis situations, either for those new to the system or for those whose deterioration is rapid or unpredicted and therefore warrants immediate action. Those who come to emergency voluntarily seeking support or advice can often settle with brief intervention and referral to outpatient care (Damsa et al. 2005). It is commonly recommended that emergency psychiatric services should concentrate on clients exhibiting imminent danger to themselves or others or to those with acute behavioural dyscontrol (Claassen et al. 2000). However, emergency psychiatric services will also likely be appropriate for anyone with serious mental illness such as schizophrenia or major mood disorders or for those with dementia when their symptoms exceed the capacity for community management (Ziegenbein et al. 2006; Chaput et al. 2008). Factors such as previous psychiatric history, pressure from family and friends, and the stability of the environment influence the need for emergency assessments, which may lead to brief interventions and/or referrals for follow-up. Further decisions regarding in-patient admissions may also be tempered by the availability of beds and other contextual variables (Mulder et al. 2005). Regarding in-patient admissions, the most appropriate cases have been deemed to be individuals who are a danger to themselves, those with psychosis, those without ability to care for themselves, those with poor impulse control, and those with significant depression – factors that appear to be consistent across hospitals and physicians (Way and Banks 2001).

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To manage individuals who need critical or urgent services, the emergency department personnel must improve their triage techniques to redirect those who should not be there to more suitable alternatives and also stream those who should be there into hospital services that meet their needs. To be consistent with the practice in most emergency departments and to address the frequent co-morbid medical conditions in the psychiatric population, a medical triage is recommended. Although “it is neither necessary nor reasonable from a time management or cost perspective to do a comprehensive medical assessment on all patients presenting to the ER with psychiatric complaints” (Upfold 2001), brief medical triage can ensure that physical factors have been appropriately addressed. Coristine et al. (2007) have shown that a structured triage including vital signs, history of significant mental illness and treatment, medical history, recent history of substance abuse, disorientation, malnourishment, and so on, can provide a streamlined but comprehensive assessment in the emergency department (figure 4.1). It has led to a reduced workload for emergency staff and shorter wait times for clients; as well, follow-up, post-discharge conditions improved, which has contributed to greater client satisfaction (Vingilis et al. 2007, 160–1). Often mental health symptoms can be precipitated by factors that are not truly psychiatric. For example, stress related to homelessness, relationship breakdowns, and other life pressures can result in escalating symptoms that lead to a perceived emergency. Using triage to redirect those with social crises – related to housing, finance, or legal issues – to an alternative non-hospital service has been shown to lead to greater efficiency and effectiveness of emergency department functioning (Coristine et al. 2007). Furthermore, the literature has also indicated the value of using a mental health triage scale, similar to those used for medical-surgical patients (Smart et al. 1999). In this method, patients are assigned ratings according to acuity – an example of a typical triage scale is presented in table 4.1. The use of triage scales has been demonstrated to affect the process and flow of emergency psychiatric activities, the quality of psychiatric services, staff competencies and attitudes, and client perceptions. Smart and colleagues (1999) showed that objective criteria, such as those within the Mental Health Triage Scale, led to more consistent triaging and more appropriate or reduced frequency of hospital admissions (see also Vingilis et al. 2007; Clarke et al. 2007; in addition, waiting times were reduced in the emergency department for psychiatric clients.

Individual Arrives in ed Triage rn Assessment Client with Mental Health Concerns Risk Assessment – to kill self or others – flight – violence “Yes” to any question Triage to stretcher with request to undress and gown Medically Assessed by ed Physician Disposition by ed Physician e.g. Medicice ceps** cc*

Yes Page security

No Triage Assessment: – Complete set of vs – Hx of significant medical illness – medical Sx – recent Hx (80) than developing (new) teams or those in rural and

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northern teams, which have generally not achieved the target of 80 clients per team (client:staff ratio of 8:1). Teams in eight of Ontario’s fourteen Local Health Integration Networks had caseloads of less than 60 clients (George et al. 2008; Ontario mohltc 2008). This is an area that merits examination, although by 31 March 2008, the team averages had increased to 75, according to data posted on the Ministry of Health and Long Term Care’s Finance and Information Management website. A related issue, especially for teams who have reached their full caseloads, is how to develop step-down capacity for clients who no longer require the intensity of ACT services. As is evident, ACT is a complex model within which to deliver treatment and rehabilitation services. Outcomes for the model have been strong for hospitalization, satisfaction, and housing, and weak in other outcomes. This result may be explained in part by differences in fidelity of implementation that have not been captured in much of the research. In addition, the small numbers of studies that have used ACT fidelity measures have also had equivocal findings, raising the possibility that the available measures, while having face validity, may not have predictive validity. The measures lean heavily on the structure and process of the team itself, without measuring the content of care being delivered. Bond et al. (2001) notes that the “father of ACT,” Leonard Stein, suggested that the strength of the model lies in its flexibility in delivering cutting-edge treatment, rehabilitation, and case management, and thus it is likely as important to measure the content of care as the model structure. For example, the literature on using evidence-based practices in ACT found the best results for supported housing and supported employment (Latimer 2005; Macias et al. 2006; Nelson et al. 2007), good employment outcomes in one older study on multiple-family psycho-education groups in ACT (McFarlane et al. 1996), and contradictory findings for co-occurringdisorders treatment in ACT (Drake et al. 2006; Fletcher et al. 2008). In domains where outcomes have been weaker, such as employment, social adjustment, and substance abuse, it may be necessary to use fidelity measures specific to these domains to assess the degree to which evidence-based interventions are being delivered. That said, there is insufficient evidence to “prove” that the main power of ACT is through delivering separate evidence-based practices, even though ACT as a whole is an evidence-based practice. Regardless of the literature, the idea of improving clinical services and using evidence-based practices within the ACT model has long been generally accepted as being

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important by ACT practitioners and is included in recent ACT practice standards (Allness and Knoedler 2003; Bjorklund et al. 2009; British Columbia Ministry of Health Services 2008; Ontario mohltc 2004) and in a pilot project of high-fidelity ACT in Japan (Ito et al. 2009). In summary, despite the fidelity research to date, we still have no definitive answer to the question of whether ACT works mainly through high fidelity to the ACT model. Yet high fidelity is only the sum of the individual ingredients of ACT. Indeed, McGrew et al. (1994) found that shared caseloads, the total number of client contacts, twenty-four-hour availability, a nurse on the team, and daily team meetings were related to reductions in hospitalizations, with the most important finding being that the role of the ACT coordinator is a critical component of achieving fidelity. Thus, the structure and process of ACT is only as good as the content and intensity of services actually provided to assist persons with severe mental illness in their recovery process. An enhanced ACT fidelity scale, the Tool for Measurement of Assertive Community Treatment (Monroe-Devita et al. 2009), is in the process of being tested in the United States and Canada and may help future researchers understand which aspects of fidelity make ACT work. Critical Ingredients Personal experiences of ACT clients and their perceptions of how ACT supports (or inhibits) their recovery journeys provide important information on the most helpful ingredients of ACT. In various studies, clients indicated that they liked staff availability, home visits, and help with everyday problems, all of which are critical ingredients of the model, although the interpersonal aspects of care were valued most by clients (Chue et al. 2004; Gerber and Prince 1999; McGrew et al. 1996; Redko et al. 2004). McGrew et al. (2002) surveyed 182 ACT clients using an open-ended question about what they liked least about ACT. They found that 44 percent disliked nothing and/or had only positive comments; 6 percent found the program too intrusive; 4 percent found it too confining; 4 found too much emphasis on medications; 3 percent found the team not understanding enough; 2 percent found it too critical; 1 percent thought the program fosters dependency or is stigmatizing; and 1 percent disliked home visits. Clients of high-fidelity programs had fewer complaints overall and fewer complaints about features considered to be specific to ACT (McGrew et al. 2002).

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Other studies examining critical ingredients of good outcomes identified the total number of contacts, the intensity of service contacts, continuity, twenty-four-hour availability, shared caseloads, and provider caseloads, indicating that ACT should be staffed to ensure that someone who knows the clients is there when needed, regardless of when or how frequently the service is required (Burns et al. 2006; Calsyn et al. 2002; Clarke et al. 2000; Kenny et al. 2004; McGrew et al. 1994; Phillips et al. 2001). This is consistent with the idea that severe mental illness does not take evenings and weekends off and that services need to be provided to account for this. The frequency or intensity of service has arisen earlier in this chapter as important, and this body of research provides even more support. Inclusive responsibility for health and social care, specific services, such as case management, housing assistance, financial assistance and nurse on team, speak to the critical ingredients of comprehensiveness (treatment, rehabilitation, and support) and a fixed point of responsibility for dealing with everything that is important for the client’s well-being. Regular home visiting and assistance with daily living relate to the critical ingredient of “in vivo” service. Finally, daily team meetings and the ACT coordinator are critical ingredients that enable the team to provide whatever service is needed, whenever it is required by ACT clients, and to do so in an organized manner. External Factors Finally, as figure 12.1 shows, the external context not only influences the fidelity of the ACT teams that are implemented, but it also affects the control conditions of standard care and affects some of the outcomes, such as the use of hospital care, through local bed availability or such factors as traditional practices. Burns et al. (2001) highlighted this as a reason that European Intensive Case Management does not appear to achieve the same results as ACT in North America, where the external (social and system) contexts are so different.

Criticisms of Act Based on Ethical Perspectives To conclude this chapter, we discuss some criticisms of ACT based on ethical grounds. Gomory’s main criticism (2001, 2002b) is that ACT is based on coercion. To begin this discussion, it is useful to consider why “assertive outreach” was invented in the first place. Instead of

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labelling clients with severe mental illness as “non-compliant” and discharging them for not participating in their care, assertive approaches recognize that negative symptoms, lack of motivation, cognitive impairments, and problems in executive functioning are some of the most disabling symptoms of severe psychotic disorders and that clients often need assertive outreach to help them overcome these aspects of their condition. On the other hand, if assertiveness is overused it could become too coercive. From a recovery, client-centred perspective, Watts and Priebe described a fundamental dilemma of ACT. It “condenses a paradox faced in community psychiatry. The model has the therapeutic aspiration of increasing personal autonomy, yet the program aims to engage people whose actions exemplify that they do not want to be involved with psychiatric services” (2002, 442). The client perspective on this dilemma was sought in a qualitative study of twelve ACT clients using a grounded-theory approach. Many clients had experienced earlier rejection of help-seeking behaviour, and all had been subjected to coercive interventions before receiving ACT services, especially around taking medications. Thus, by the time they came to ACT, the clients had an increasing level of arousal concerning issues of power. Participants described critical ingredients in becoming engaged with ACT with respect to social interventions such as help with housing or benefits or providing social contact. The researchers suggested that it is important for ACT staff to model a more collaborative therapeutic relationship to attenuate the clients’ previous negative experiences of power and control issues (Watts and Priebe 2002). In a summary of scientific research and clinical issues for ACT practice, Rosen et al. (2007, 818) state that “while most service users do not perceive ACT as coercive, occasional issues around coercion persist, largely unsupported by data.” He quotes Solomon (2008), who summarized evidence demonstrating that “coercive practices do not prevail in ACT teams, with case managers relying on verbal negotiation rather than coercion and generally using involuntary admissions and other external authorities with less than 5% of consumers.” Ohlenschlager et al. (2007) found no difference in coercion when comparing ACT-like interventions with intensive in-patient rehabilitation or standard care for persons with first-episode schizophrenia spectrum disorders, and the clients in the ACT-like programs spent less time in hospital. Moser and Bond (2009) studied more objective indicators of overt coercion, such as representative payeeship

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and intensive medication monitoring, in twenty-three teams across one state and found a highly variable extent of agency control. The strongest predictor for coercion consisted of client characteristics, not fidelity to the ACT model. This area merits further research in ACT, as suggested in an article on ACT and recovery (Salyers and Tsemberis 2007). A related criticism is that ACT/Intensive Case Management “compromises patient autonomy” more than other forms of community mental health care (King 2006). To balance this criticism, it is useful to note many ACT practices that support client autonomy and promote recovery. Witheridge (1991) described the practices of supported housing or supported employment (both of which are used in ACT) in which the client’s choice of living arrangements or work is the starting point for selection, rather than the practice of just providing group homes or sheltered workshops. In supported housing “the client carries the keys” and can make decisions about his or her own lifestyle and the daily rhythm of life. In supported housing or supported employment the “concept of independence is modified, and supported or assisted independence was viewed as a success” (Witheridge 1991). Data from the Ontario ACT outcome-monitoring system show that the longer clients receive ACT services, the more independence they achieve in their housing (Ontario mohltc 2008), which is consistent with the findings of many ACT studies. Ontario, Canada, supports one of the largest ACT programs in the world, with eighty teams in 2009 (Ministry of Health and Long-Term Care 2009), highfidelity ACT standards, and government-supported province-wide program evaluation to maintain and improve the fidelity of ACT services. These teams provide an ideal opportunity to understand more about client recovery and other critical issues in the field. An Ontario-wide project studied the relationship between fidelity, client outcomes, and recovery orientation of ACT services as measured by multiple stakeholders including clients (Kidd et al. 2010, in press). Fidelity was measured with the Dartmouth ACT Scale (Teague et al. 1998), and the Recovery Self Assessment Questionnaire (O’Connell et al. 2005) evaluated the recovery orientation of sixty-nine ACT teams (with 1,259 clients) from the perspective of consumers, family/ support providers, service providers, and administrators. There was no indication of a substantial use of coercion in the reports of staff, family, clients, and managers. Limitations included the use of a

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self-report measure and routine outcome data that were aggregated by the team. In another Ontario project, Bishop and Vingilis (2006) are studying how ACT affects clients’ experience of empowerment as part of a causal path toward improvement. Williamson (2002) reviewed literature that contributed to the ethical debates regarding ACT as being “coercive and paternalistic” and suggested an alternative ethical basis for supporting delivery of assertive outreach services to a reluctant client group, which focuses more on the clients’ values and areas of assistance with which they express genuine appreciation and satisfaction (Williamson 2002). Trinh et al. (2008) described three cases in which ethics consultation helped their ACT team think more critically about the “ethical underpinnings of (the) clinical decisions” in trying to balance “client autonomy against the consequence of client noncompliance with treatment.” The literature described does not settle the debate, but it does highlight the fact that ACT practitioners should always strive to find common ground with their clients, remain vigilant in using collaborative relationships, and if needed, seek ethics consultation, since coercive measures are sometimes necessary and legally mandated/supported under various forms of mental health legislation. Gomory’s second criticism (2001, 2002a,b) is that ACT reduces hospitalization merely by making the administrative decision in advance not to admit clients. It is hard to know how this conclusion has been reached. It may be that Gomory has anecdotal evidence to this effect, but it is not part of accepted ACT practice. The initial philosophy of ACT in the United States was to transfer the locus of treatment and rehabilitation for persons with severe mental illness from long-term institutions to the community while at the same time improving their quality of life and avoiding adverse outcomes. In the United Kingdom, the Team for Assessment of Psychiatric Services found that moving out of the mental hospital into well-resourced non-hospital settings improved life circumstances and social functioning of long-stay patients (Leff and Trieman 2000). Even patients who were initially reluctant to leave the long-term wards at psychiatric hospitals eventually came to prefer community living and did not want to return to hospital. ACT is able to help people live where they want to live, rather than admitting them frequently or for long periods. Hospitalization is used only as clinically necessary, but it does not usually need to be used for long periods, since the ACT

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team operates 24/7/365 as a mini-system of care in the community and can safely discharge its clients earlier than would be possible without ACT services.

Summary and Recommendations We have summarized the research on ACT’s efficacy, effectiveness, and cost-effectiveness, and we have highlighted gaps in the literature and described research and program evaluation projects that are related to these gaps. In addressing a major unanswered question on how ACT works, we used a theoretical framework for ACT evaluation to discuss the literature on how and why ACT might work by examining research on ACT client recovery principles and ACT implementation. Finally, we discussed some criticisms of ACT on philosophical/ethical grounds. To end, we would like to share some suggestions for further research and evaluation of ACT. 1 It would be easier to interpret and compare research on ACT in different countries and jurisdictions if there was an internationally acceptable method to measure the degree of fidelity to the ACT model. In particular, there is a specific need for a reliable and valid way to measure and report the frequency of therapeutic contacts with ACT clients. This is important as governments try to minimize costs, since the highest cost for ACT teams is the number of qualified staff available to deliver services at a frequency that is commensurate with clients’ needs. 2 It would also help the interpretation of results of ACT research if there were a way to measure the influence of local context on the outcomes observed. It may be useful to employ a comprehensive evaluation framework to help interpret outcome studies in the context in which they are carried out, such as the differences in urban vs rural ACT adaptations. 3 Research into the relationship between fidelity and recovery would benefit from studies that use individual client data and employ both qualitative and quantitative methods. This research should specifically address the issue of therapeutic assertiveness vs coercion and the potential for compromised client autonomy. To study “recovery” as envisioned by Anthony, research needs to

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move beyond randomized controlled trials and concrete outcomes. Anthony suggested using qualitative methods and studying service principles and practices, rather than program models. Moreover, recently there has been a heightened interest in measuring the orientation of all mental health programs towards recovery and finding means through which the theory and rhetoric surrounding recovery might be operationalized (O’Connell et al. 2005; Resnick et al. 2005). We need to understand more about the process of recovery from the perspectives of ACT clients themselves. It would be helpful to discover more about which elements of ACT are related to which outcomes and to learn more about the sequence of changes that occur in clients as they move forward in their recovery journeys. This could be facilitated by using clientdeveloped ways to measure the recovery orientation of mental health services and how this relates to their experience of ACT. More rigorous research using ACT fidelity measures is needed to make evidence-based decisions about the value of implementing ACT teams for persons with severe mental illness and forensic issues or developmental disabilities. New jurisdiction-wide ACT programs are encouraged to use rigorous methods for outcome evaluation of ACT in their own contexts. These should include a way to measure fidelity on an ongoing basis to prevent program drift. In Canada currently, the province of British Columbia has recently adopted updated evidence-based standards for ACT implementation (British Columbia Ministry of Health Services 2008), with plans for outcome evaluations that answer the priority questions of multiple stakeholders. It will provide a unique opportunity for inter-provincial collaboration within Canada to learn more about the effectiveness of ACT in different jurisdictions, especially rural adaptations. In agreement with a naturalistic study by Hackman and Stowell (2009, 1–5), further research needs to be done on effective ways to develop step-down (and step-up) capacity. This could be done within teams or by partnerships with existing case management programs. In the current integration environment in Ontario and other jurisdictions, the latter may be a strategy worth exploring and evaluating. We could also use the developing international ACT research collaboration (Deuchar et al. 2008) to study ACT

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innovations such as the Dutch “Functional” ACT, in which ACT is one function in multi-functional regional case management teams (Velhduizen 2007) and current Ontario practice of “step-down” ACT.

notes We would like to thank the Centre for Assessment & Research on Mental Health and Addictions (CARMHA) at Simon Fraser University, British Columbia, for their extensive help with literature searches. 1 The acronym ccar in figure 12.1 refers to Colorado Client Assessment Record, a widely used data collection form for persons in receipt of mental health services.

13 Supported Employment Eric Latimer

Introduction People with severe mental illness (mainly schizophrenia, schizoaffective disorders, bipolar disorders, and major depression) represent 2 to 3 percent of the population (Kessler et al. 1999). Relatively few among this population work: even in the United States, where unemployment rates are low, only about 10 to 30 percent of people with severe mental illness work, including in sheltered settings (Rosenheck et al. 2006; Salkever et al. 2007). Yet various surveys conducted among people with severe mental illness who are users of mental health services suggest that about 60 to 70 percent of them would like to work (Drebing et al. 2004; McQuilken et al. 2003; Mueser et al. 2001). Studies suggest that work provides many benefits for people with severe mental illness, as it does for the general population. The quality of life of people with severe mental illness who are working, whether measured subjectively or according to a number of objective measures, is higher than that of others who are not working (Priebe et al. 1998). Entering into employment has been associated with improvement of symptoms, enhanced self-esteem, and greater satisfaction with vocational rehabilitation services and finances (Becker et al. 2007; Bond et al. 2001; Burns et al. 2009; Mueser et al. 1997; Salyers et al. 2004; Schneider et al. 2009). Work also provides a respite to the families of people who have severe mental illness (Bell et al. 1996; Solomon and Draine 1995). More recently, work has also come to be seen as essential to recovery (Mental Health Commission of Canada 2009; Provencher et al. 2002).

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Over the past several decades, a wide range of vocational rehabilitation programs or options have been developed for people with severe mental illness. Supported employment excepted, these programs can be grouped into one of three types: (1) programs that do not aim to help clients progress towards competitive employment and that engage clients in activities of a mostly occupational nature, such as day-treatment centres; (2) programs that aim to help clients progress towards more independent employment, such as clubhouses, but that do not place people directly into competitive employment; and (3) affirmative or consumer-run businesses, in which a third or more of jobs are reserved for people with severe mental illness (or other disabilities), who are paid at the minimum wage or better. Consumer-run businesses (also known as alternative businesses), which are especially prominent in Ontario, differ from affirmative businesses (also known as social enterprises) in that their entire workforce, including management, consists of consumer/survivors. Whether affirmative or consumer-run, such businesses operate in a competitive market and thus offer meaningful jobs; they are also likely to offer a greater sense of community than typical competitive jobs. This may be why people employed in such businesses do not often transition to competitive jobs (Warner and Mandiberg 2006). Supported employment represents an alternative approach to helping people with severe mental illness attain meaningful employment: rather than providing jobs that are more accommodating for people with mental illness, vocational advisers help people with severe mental illness obtain and keep competitive jobs. Since the early 1990s, experimental research has shown that such an approach can be effective. Supported employment involves, most fundamentally, a shift from the traditional “train-place” paradigm to one of “placetrain”: the person is placed directly into a competitive job and then continues to receive support as he or she learns through direct experience in the regular labour force. Among the various formulations of supported employment, the one that has received the most attention internationally is called Individual Placement and Support. As summarized below, evidence now clearly shows that, overall, Individual Placement and Support is more effective than more gradual approaches at helping people spend time and accumulate earnings in competitive work, at least over a horizon of a few years.

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Even programs that follow the Individual Placement and Support model closely, however, do not help all clients integrate into the labour force successfully. In randomized trials, approximately one-third of clients do not obtain a single competitive job over the follow-up period (usually one to two years). Perhaps another third continue to have a less than satisfactory work experience (Corrigan et al. 2008, 207). Two basic responses have been pursued. One is to seek to improve on the Individual Placement and Support model, so that more people can integrate into the competitive work force more and more successfully. A second is to maintain programs that offer alternatives to competitive employment. This chapter will begin with a discussion of a central premise of supported employment, namely, that competitive employment is preferable to sheltered employment. A brief description of the Individual Placement and Support model will follow, together with an account of the evidence concerning its effects on vocational and non-vocational outcomes. The chapter then discusses the possibility that other supported employment models might be preferable to Individual Placement and Support. Evidence and current lines of investigation concerning ways of increasing the effectiveness of Individual Placement and Support will then be outlined. The chapter concludes with an analysis of policy implications.

Why Favour Competitive Employment? There are both practical and theoretical reasons to look for competitive employment opportunities for people with severe mental illness. At a practical level, in virtually any setting there will be a greater number and variety of potential competitive than non-competitive jobs available, and these will often also offer greater flexibility in hours of work per week. A person with mental illness is then more likely to find a competitive job that corresponds to his or her skills, interests, and willingness or ability to work more or fewer hours and one that is located reasonably close to home. Second, while affirmative businesses may be expected to become economically self-sufficient after an initial start-up period (Warner and Mandiberg 2006), in some cases they can continue to receive significant subsidies. In Québec, provincial subsidies to a certain class of affirmative businesses (entreprises adaptées) amount to over $15,000 per full-year disabled person per

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year, almost triple the comparable cost of one year of support from a supported employment program (Latimer 2008). Supported employment goes further, however, than these arguments would imply in pursuing competitive work only, to the virtual exclusion of all other types of work. In doing so, it implicitly asserts that competitive work is more helpful to clients, or more conducive to recovery, than non-competitive work and that clients who want to work can be helped to obtain competitive work as easily as noncompetitive work. Is competitive work more conducive to recovery? Quantitative studies supporting the assertion that even work in general, let alone competitive work in particular, contributes to recovery are almost non-existent; indeed, we are only beginning to learn how to measure recovery as an intervention outcome (Bond et al. 2004; see this volume, chapter 12). But several studies and testimonies suggest an important association between the experience of recovery and community integration, that is, a life spent in mainstream settings: in apartments, in job and leisure activities available to all and shared with others who do not have a severe mental illness (see Bond et al. 2004 for a summary). Work in competitive settings paid at the minimum wage or better and available to anyone clearly tends to contribute to community integration in a way that work in settings reserved, or partly reserved, for people with disabilities does not. Empirical studies suggest that competitive work yields better nonvocational outcomes for people with long-term mental illness than structured activity in a day treatment centre (Eklund et al. 2004). Evidence concerning the relative benefits of competitive jobs compared to paid but non-competitive ones appears more ambiguous. One secondary analysis of data from an Individual Placement and Support study compared clients who obtained competitive jobs as opposed to those who worked in paid, set-aside jobs or did minimal or no work. Those who worked in competitive settings showed significant gains in satisfaction with finances, leisure, and services, as well as in self-esteem and symptoms, compared to those with minimal or no work; the group who worked in non-competitive settings showed no such advantage (Bond et al. 2001). One qualitative study, on the other hand, found that clients in group segregated settings experienced more support from co-workers and supervisors than people in competitive settings, though the long-term consequences of this were unclear (Rollins et al. 2002).

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It would seem intuitively obvious that setting up non-competitive jobs designed for people with severe mental illness (or people with disabilities in general) and making those available to people with severe mental illness in addition to competitive employment would increase time spent in paid employment. We could locate only one study comparing Individual Placement and Support with an Individual Placement and Support–like program offering both competitive and non-competitive employment options. Over a two-year follow-up, outcomes for time in paid employment were statistically identical for the two programs (Bond et al. 2007). Other studies provide further, indirect evidence that the gains from allowing vocational advisors to refer clients to non-competitive jobs are at best modest. A trial comparing the Choose-Get-Keep model with enhanced state vocational-rehabilitation services in Massachusetts found that in spite of the careful attention paid to model fidelity in the CGK condition, over a two-year follow-up 37 percent of ChooseGet-Keep clients had obtained a competitive job and 60 percent paid employment of any kind (Rogers et al. 2006). As described below, most trials of Individual Placement and Support have attained 60 percent competitive-employment rates or better over a twelve- to twenty-four-month period. (The Choose-Get-Keep trial report does not provide data on the time spent working.)

The Individual Placement and Support Model of Supported Employment Description of the Model The Individual Placement and Support model is often described as following these seven principles: 1 Clients are placed directly into competitive jobs (jobs that pay the minimum wage or better and that are not set aside for people with disabilities). 2 Client preferences drive the characteristics of jobs that are sought. 3 All clients who desire to work are eligible to enter the program – there is no pre-screening for work readiness. 4 Clients receive benefits counseling. 5 Job search is rapid, with no preparatory phases. 6 Vocational advisors work closely with the client’s clinical team.

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7 Clients receive individualized follow-up as long as the client desires it (Bond 2004; Bond et al. 2008). A recently updated fidelity scale, the supported-employment fidelity scale, specifies in greater detail how a program must be implemented if it is to follow the Individual Placement and Support model closely (Dartmouth Psychiatric Research Center 2008). This fidelity scale includes additional elements not directly implied by the principles just listed, such as caseload size (should not exceed twenty clients per vocational advisor); the range of tasks carried out by the vocational advisor (all vocational tasks from job development to on-the-job coaching); and the joining of vocational advisors as a vocational unit (rather than advisors being simply embedded into a clinical team, as would happen with an Assertive Community Treatment team (Stein and Santos 1998)). A book further describes in even greater detail the prescribed functioning of an Individual Placement and Support program (Becker and Drake 2003), and training videos are now available on the web as well (Dartmouth Psychiatric Research Center 2007). Evidence concerning Vocational Outcomes We identified thirteen randomized controlled trials of Individual Placement and Support and four of programs that could be qualified as precursors to or variants of Individual Placement and Support. These studies used a variety of programs as control conditions, all of them involving some reliance on non-competitive job placements. Some, but not all, control conditions involved a vocational advisor who supported the client. As these trials normally involve real-world implementations of Individual Placement and Support, compared to real-world programs in naturalistic settings, we interpret their results as speaking largely to the effectiveness of the Individual Placement and Support model, and not merely to its efficacy (Corrigan et al. 2008). Of the thirteen Random Controlled Trials of Individual Placement and Support, seven were conducted in the United States (Bond et al. 2007; Drake et al. 1999; Drake, McHugo, et al. 1996; Gold et al. 2006; Lehman et al. 2002; McHugo et al. 1998; Mueser et al. 2004; Twamley et al. 2008), one in Australia (Killackey et al. 2008), two in Hong Kong (Tsang et al. 2009; Wong et al. 2005), one in Canada (Latimer et al. 2006), one in England (Howard et

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al. forthcoming), and another, a six-country trial, in Europe (Burns et al. 2007). The four studies of Individual Placement and Support variants were all conducted in the United States (Bond et al. 1995; Chandler et al. 1997; Gervey and Bedell 1994; McFarlane et al. 2000). In all of these studies except one, the percentage of Individual Placement and Support clients who obtained a competitive job during the study period was at least nearly double, and sometimes several times greater, than the percentage of clients who did so while in other types of programs. The sole exception is the SWAN study, conducted in London, in which the difference in employment rates after one year between the Individual Placement and Support and control conditions, although favouring Individual Placement and Support, was not statistically significant (Howard et al. forthcoming). In this implementation of the Individual Placement and Support model, however, vocational advisers had very few contacts with clients, which is likely the major reason for the observed lack of effectiveness (Latimer forthcoming). A recent synthesis reports that the time to first job averages ten weeks less than for controls. If all study participants are taken into account, Individual Placement and Support clients worked 2.5 times more weeks than controls; however, weeks worked were virtually the same if one compared only Individual Placement and Support and control-group participants who did obtain competitive employment – about half the weeks of the year on average (Bond et al. 2008). (These means may not be altogether comparable, however: control group clients who do obtain jobs may be more motivated on average than Individual Placement and Support clients who obtain jobs, and this difference could also affect job duration.) Furthermore, the studies that report competitive earnings all show higher earnings for Individual Placement and Support participants, generally by a factor of more than two. (The Canadian trial is the one showing the smallest difference, in proportion, between Individual Placement and Support and control participants on this measure – $962 vs $521.) We also identified an additional eleven studies relying on various non-randomized designs (Bailey et al. 1998; Becker et al. 2001; Drake et al. 1994; Drake, Becker, et al. 1996; Gold and Marrone 1998; Lucca et al. 2004; Oldman et al. 2005; Perkins et al. 2005; Rinaldi et al. 2004; Rosenheck and Mares 2007; Twamley et al. 2005). The studies have included analyses of the effects of converting day-treatment centres into Individual Placement and Support

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programs (Bailey et al. 1998; Becker et al. 2001; Drake et al. 1994; Drake, Becker, et al. 1996), including one instance in Canada (Oldman et al. 2005). Without exception, these studies have reported significantly better competitive employment outcomes for the Individual Placement and Support condition. Most studies have recruited among unemployed users of public mental health services of a wide range of ages, users who expressed an interest in working. One random controlled trial and one prepost study, however, targeted specifically people experiencing a first psychotic episode, extending the model to put significantly greater emphasis on supported education (Rinaldi et al. 2004; Killackey et al. 2008). Considering further education in normal settings as equivalent to competitive employment, vocational outcomes were comparable to those that Individual Placement and Support achieves in other populations. Yet another trial limited subjects to people between the ages of forty-five and sixty, again with comparable outcomes (Twamley et al. 2008). Aside from the London SWAN study alluded to earlier, the trial in which competitive job placement rates were lowest was the one where clients were not screened for interest in working (Lehman et al. 2002). The evidence is thus unequivocal that evidence-based supported employment, or Individual Placement and Support, helps more people obtain a competitive job and work longer in competitive settings than the traditional alternatives to which it has been compared. The studies also show that they work more hours and earn more income in competitive settings over the same period. Job duration among Individual Placement and Support clients who do work appears, however, no greater on average than among non-Individual Placement and Support clients who do work, although limited follow-up duration prevents an entirely reliable comparison (Bond et al. 2008). Non-vocational Outcomes As mentioned in the introduction, none of the Individual Placement and Support programs tested were able to help all the clients obtain even one competitive job over the study follow-up. Across the twelve Individual Placement and Support trials identified (excluding the SWAN study for the reasons given above), the highest percentage of clients who obtained a competitive job was 78, and the lowest 27, with a median of 64. This implies that a large minority of people who entered

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an Individual Placement and Support program were not able to obtain a competitive job. Furthermore, even among those who worked, most did so only on a part-time basis, for only part of the study period. This result probably helps to explain why these studies have yielded, in spite of the evidence on the benefits of work summarized in the introduction, virtually no evidence of gains from being assigned to the Individual Placement and Support group on such variables as symptoms, self-esteem, or quality of life. It appears likely that the amount of employment was too little, with too many clients having no employment, for there to be a statistically significant difference on such variables between the Individual Placement and Support and control groups. Furthermore, it is common in these studies for clients to be assigned to the Individual Placement and Support group to realize, once they are enrolled in the study, that they really are not much interested in working. In a natural setting, such clients would leave the program and be replaced by others, but in a rigorous randomized study they need to be kept. Thus, the randomized studies may well understate the effects on non-vocational outcomes of being assigned to an Individual Placement and Support program. There is evidence, however, that clients who do work benefit from working. In two long-term follow-up studies, many clients indicated that Individual Placement and Support had helped them gain greater self-esteem and self-confidence (Becker et al. 2007; Salyers et al. 2004), and in one of the studies also that it had helped control their symptoms (Becker et al. 2007). Admittedly, such studies are open to alternative interpretations – clients’ self-reports may have been positively biased. In addition, data from three Individual Placement and Support studies have been analysed to look for associations between having entered into work and various non-vocational outcomes. In all three cases, clients who worked (or, in one study, who worked in competitive, as opposed to non-competitive, settings) experienced reduced symptoms and improved self-esteem (Bond et al. 2001; Burns et al. 2009; Koletsi et al. 2009; Mueser et al. 1997). The two studies that examined this outcome also reported more satisfaction with finances and vocational services among clients who worked (Bond et al. 2001; Mueser et al. 1997). Thus, while participation in an Individual Placement and Support program as such may not yield significant benefits in non-vocational domains, working, which participation in the program facilitates, does appear to yield such benefits. Similar results have also been reported for clients who entered

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supported-employment programs not necessarily close to Individual Placement and Support (Schneider et al. 2009).

Effectiveness of Other Supported Employment Models There are a number of other ways of delivering supported employment (Corbière and Lecomte 2009). For example, in Australia nongovernment organizations have been reported to offer a service referred to as “open employment,” which differs from Individual Placement and Support in that there is little integration between vocational services and mental health services, and clients are screened for work readiness (Waghorn and Lloyd 2005). In England, a variety of ways of implementing supported employment have recently been documented (Boyce et al. 2008). In the Netherlands as well, various ways of implementing supported employment have been reported, including in some cases dividing the work of a vocational advisor among specialists (i.e., one person finds jobs, another coaches clients on the job). In some cases a “buddy” is found on the job site who can assume some of the functions of a job coach (Hoekstra et al. 2004). Even in the United States, where supported employment and the Individual Placement and Support model originated, many variations exist (Evans and Bond 2008). Although there is little direct evidence concerning any of these alternative models, various forms of indirect evidence help to define more narrowly the characteristics of an effective supported-employment program. This can be done by considering, first, the evidence for each of the principles of the Individual Placement and Support model, beyond the preferability of competitive employment, which has already been addressed; and second, the association between program fidelity and outcomes.

Support for Individual Principles of the Individual Placement and Support Model and Association of Fidelity with Outcomes Zero exclusion The principle of zero exclusion (making the program available to all who express a desire to work) cannot be supported on the basis of evidence alone. A number of studies indicate that certain

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clinical factors do tend to be associated with greater success in a supported-employment program: fewer positive and negative symptoms and higher cognitive functioning (McGurk and Mueser 2004), the absence of post-traumatic stress disorder (Mueser, Essock, et al. 2005), a diagnosis other than schizophrenia, a higher self-perceived functional level, and fewer prior hospitalizations (Razzano et al. 2005). Interestingly, however, even people with schizophrenia who have active positive symptoms and people with substance-use disorder, may find and keep a job (Becker et al. 2005; Kessler 2004; Mueser et al. 2003). Among non-clinical factors, a more substantial previous work history is associated with greater success in a vocational rehabilitation program (Alverson et al. 1998; Drake, McHugo, et al. 1996), as are more active efforts to find oneself a job independently of a supported-employment program (Alverson et al. 1998; Alverson et al. 2006; Schneider et al. 2009). It now appears clear that a program could improve its vocational outcomes by being selective among clients who express an interest in working. Some clients who would have benefited from the program, however, would be excluded. The situation is analogous to what prevails for many kinds of medical treatment with uncertain results: many forms of cancer treatment, for example, are offered to all patients who might benefit from them. Put differently, this principle has been defended in part on the grounds of the ethical principle of autonomy and the philosophical commitment to client-centredness (Corrigan et al. 2008, 197). We now briefly consider the evidence in support of each of the remaining principles, based on earlier work by Bond (2004). Attention to Client Preferences in Job Selection A few studies indicate that clients stay longer in jobs that better match their preferences (Becker et al. 1998; Becker et al. 1996; Mueser, Becker, et al. 2001); according to another study, clients who were more satisfied initially with their job tended to keep it longer (Xie et al. 1997). Like the principle of zero exclusion, this one also rests in part on the desire to respect client autonomy and to provide client-centered services. Rapid Job Search At least three studies have tested directly and support the hypothesis that a rapid job-search strategy is more effective at helping clients

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work more in competitive settings (Bond and Dincin 1986; Bond et al. 1995; Drake, Becker, et al. 1996). Yet another, qualitative study from Kansas comparing supported-employment programs that were more effective at helping their clients work in competitive settings with others that were less effective also found that the more effective programs more quickly determined the type of job they would seek for a client and avoided preparatory phases (Gowdy et al. 2003). Integrating Vocational Advisers into Clients’ Clinical Teams A substantial number of studies using both quantitative methods (Chandler et al. 1997; Drake, McHugo, et al. 1996; Drake, McHugo, et al. 1999; Gold et al. 2006; McFarlane et al. 2000; Mueser et al. 2004) and qualitative methods (Becker et al. 2007; Drake et al. 1995; Drake, Becker, et al. 1996; Gowdy et al. 2004; Salyers et al. 2004) support the importance of this principle. The qualitative studies in particular suggest several reasons why this principle is important. A person’s mental illness and work life are mutually interdependent, and the effectiveness of interventions in each area is enhanced by taking the other into account. Closer integration between vocational advisers and clinicians also helps ensure that clients receive the same message concerning the value and possibility for them of working from clinicians as well as vocational advisers (Drake et al. 2003) – indeed it helps clinicians become themselves more convinced of this (Gowdy et al. 2004). The number of studies supporting this principle, the variety of quantitative and qualitative methods that they employ, and their unanimity together strongly support this principle. Individualized and Long-Term Support This principle actually contains two elements. Evidence and ethical arguments for the importance of attention to consumer preferences in the choice of jobs for clients, which have already been summarized, extend naturally to individualized follow-up as well. Once a job is found, the nature of follow-up will most obviously differ according to whether the client has chosen to disclose his or her illness to the employer. As for long-term support, there could be two reasons for not offering it: (1) that it is not necessary – whatever benefit clients may receive from a supported employment program they will receive over an initial period of follow-up; and (2) that some clients should not be offered it because they clearly are not benefiting from it. Concerning the first, one two-year follow-up study of subjects of one

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of the early Individual Placement and Support trials concluded that sustained competitive employment depended on continued services from the Individual Placement and Support program (McHugo et al. 1998). Furthermore, two longer-term studies found that many clients, eight to twelve years following their entry into an Individual Placement and Support program, attributed their vocational success during that period in part to the long-term support they had been able to receive (Becker et al. 2007; Salyers et al. 2004). While the new fidelity scale allows for the step-down of clients who have been working steadily to mental health services, it is obvious that should the client desire re-entry into the vocational adviser’s caseload following job loss, this preference needs to be allowed (principle of zero exclusion). As for excluding clients who appear not to have been benefiting from the program, one of these studies also reports that clients who ultimately had positive vocational outcomes were not necessarily successful in the first year of follow-up (Salyers et al. 2004), suggesting that lack of initial success does not necessarily imply long-term failure. This suggests that the arguments for offering supported employment to all who initially express a desire to work are equally relevant to the principle of offering follow-up of indefinite duration. Provision of Benefits Counselling One recent study suggests that providing systematic benefits-counselling significantly increases employment earnings (Tremblay et al. 2004). In the two long-term studies already mentioned, clients who worked successfully often stressed the importance of such information (Becker et al. 2007; Salyers et al. 2004). Among these principles, the three for which evidence remains on its own less than compelling are attention to consumer preferences, provision of benefits counselling, and long-term support. All these principles can also be justified to some extent on ethical grounds. As mentioned earlier, however, there is more to the Individual Placement and Support model than its principles. An additional line of evidence supporting the Individual Placement and Support model as more precisely formulated in the Individual Placement and Support fidelity scale comes from several studies that, taken together, suggest that higher model fidelity is associated with improved employment outcomes for clients (Becker et al. 2001; Becker et al. 2006; Bond 2007; Burns et al. 2007; McGrew and Griss 2005; Rosenheck and

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Mares 2007). Because of the small numbers of programs considered in each of these studies, however, they do not allow any determination of which particular elements of the fidelity scale may most contribute to outcomes. Furthermore, the fidelity scale has recently been expanded from fifteen to twenty-five items (Dartmouth Psychiatric Research Centre 2008). Evidence concerning the association between fidelity as measured using this expanded scale and outcomes is not yet available. In conclusion, if the goal is to help clients attain competitive employment and if the decision is taken to give all clients who desire help to find competitive employment an opportunity to enroll in a supported employment program, then there is good evidence, as well as ethical justification, to follow the principles of the Individual Placement and Support model. There is also evidence that aiming for higher fidelity to the model as measured by the original Individual Placement and Support fidelity scale tends to yield better vocational outcomes, but the possibility nonetheless remains that gains might be achieved by modifying some elements of the Individual Placement and Support model or by adding to it.

Improving the Effectiveness of Individual Placement and Support Programs In practice, the Individual Placement and Support model turns out to have three significant limitations: many clients who register in such programs still do not obtain competitive jobs; job duration appears, in most studies, to be no higher than with alternative approaches; and the jobs, while fairly varied, tend to be low-skilled. Several lines of investigation are currently being pursued, or could be pursued, to mitigate these limitations. They can be divided into two groups: optimizing implementation of the current model and potential model enhancements.

Optimizing Implementation of the Current Model High-Fidelity Implementation As noted earlier, program fidelity has been associated with better outcomes. Some research has considered how best to help programs attain high fidelity. One general conclusion of this kind of research, drawn from studies of many types of service providers, is that initial staff training must be supplemented with monitoring and feedback

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over time (Fixsen et al. 2005). Precise ways of supporting the training and development of evidence-based practices such as Individual Placement and Support, based on trial and error rather than on formal experimental evidence, have been described (Rapp et al. 2007).

Effectiveness of Vocational Advisors Drake and colleagues note a significant variation in the effectiveness of different vocational advisors: while some barely manage to help 25 percent of their clients find work, others within the same program can exceed 75 percent (Drake et al. 2006). Much of this variation may be related to level of skill in job development (Swanson et al. 2008). Some also likely results from their ability to enhance client motivation to work, directly and also by influencing clinicians to view work as possible and desirable for more of their clients (Gowdy et al. 2003; Gowdy et al. 2004). Further research is needed to determine how program managers can more reliably identify candidates with the greatest potential to become effective vocational advisors and how to help them become more effective once they are hired (Drake and Bond 2008). Program Incentives It is common for programs that are intended to help people find jobs to be given financial incentives to encourage the achievement of targets. Often these incentives have rewarded short-term placement, which has discouraged long-term follow-up. One recent trial tested a more sophisticated incentive scheme involving payment in return for achievement of five employment milestones. The scheme appeared to increase milestone attainment, but this result did not yield improvements on non-milestone vocational or non-vocational measures such as quality of life or functioning (McGrew et al. 2005). Staff perceptions of the scheme were mixed, with concerns that performance schemes would encourage client selection (McGrew et al. 2007). More research is needed on how best to design incentives for evidence-based supported employment programs. Rules concerning Benefits The rules governing the effects of earned income on disability payments and health benefits are likely to influence the cost-effectiveness of an Individual Placement and Support program. In the EQOLISE study, clients at sites where, according to their vocational advisors,

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working posed a greater risk of resulting in a reduction in income for the client (i.e., sites where there existed a “benefits trap”) were less likely to work, regardless of whether they were receiving Individual Placement and Support or other services (Burns et al. 2007). Furthermore, in the one long-term follow-up study of Individual Placement and Support clients that has examined this issue, clients reported working part-time not only because it was easier, but also because they feared working more would compromise their disability income and health benefits (Becker et al. 2007). In Canada, Individual Placement and Support clients face smaller risks than in the United States from working, in that hospital and physician services remain free of charge regardless of income. Coverage of medications for people who leave disability status, however, varies by province. The proportion of earned income that is subtracted from a client’s disability benefits also varies by province. Constructing rules concerning benefits that simultaneously protect people with disabilities, reward movement towards work, and are equitable toward other groups in society is yet another topic that requires more investigation.

Potential Model Enhancements Systematic Approaches to Enhancing Client Motivation In addition to recruiting and training vocational advisers who will help enhance client motivation to work by communicating hope and a positive attitude towards work, several more explicit approaches ranging from motivational interviewing to contingency management have been or are being investigated to reinforce client motivation (Drake and Bond 2008). Workplace Skills Training At least three studies have explored the effects of a training package, known as Workplace Fundamentals, that is intended to develop workplace skills and increase job duration. These skills include, for example, how to deal with a problem at work and how to interact with a supervisor (Mueser, Aalto, et al. 2005; Wallace and Tauber 2004). The first two studies have not succeeded in showing that such training can increase job duration. It is possible, however, that the limitations of these studies (small sample in the first case, sample of individuals with unusually high educational attainment in the second) contributed to these negative results (Liberman 2006). In a

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recently published trial carried out in Hong Kong, an enhancement of Individual Placement and Support with social skills training appeared to achieve a dramatically greater competitive employment rate (78.8 percent employment rate vs 53.6 percent for Individual Placement and Support alone and 7.3 percent for the control group), as well as significantly longer average job tenure (Tsang et al. 2009). It remains to be seen whether this finding can be replicated. Cognitive Remediation Cognitive limitations are common among people who have severe mental illness, especially those with schizophrenia (McGurk and Mueser 2004; Wexler and Bell 2005). In the absence of supported employment, these limitations impede vocational success – a causal link in that direction is well established (McGurk and Mueser 2004). Clients with more significant cognitive limitations tend to require a greater part of the time of vocational advisers (McGurk et al. 2003). At the end of a systematic literature review, McGurk and Mueser conclude that supported employment tends to compensate for these cognitive limitations, but only partially (McGurk and Mueser 2004). A study carried out among vocational advisers working under the Individual Placement and Support model identified a large number of strategies that the vocational advisers used to compensate for limitations in attention, psychomotor speed, memory, and problem-solving ability: for example, breaking up a task into smaller components that the client is encouraged to master progressively through repetition (McGurk and Mueser 2006). A few studies also suggest that some cognitive limitations can be attenuated or even eliminated by means of systematic training and that such training can have a positive impact on the capacity to keep a job (Wexler and Bell 2005). Supported Education and Career Development Supporting clients, when this is consistent with their preferences, in attaining higher education or skills development in regular settings (i.e., settings not designed specifically for people with disabilities) is consistent with Individual Placement and Support (Becker and Drake 2003). Except in the case of studies targeting clients who recently experienced their first psychotic episode (Killackey et al. 2008; Nuechterlein et al. 2008; Rinaldi et al. 2004), however, studies of Individual Placement and Support normally focus on reporting

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work-related outcomes, with little or no mention of education. The recently revised supported-employment fidelity scale does mention help with career development, including assistance with education (part of item 11 (Dartmouth Psychiatric Research Center 2008)), but more research is needed to determine how to best integrate supported education and career development within Individual Placement and Support. Improved Management of Psychiatric and Co-morbid Illnesses Medication has an important influence on the capacity of people with psychotic symptoms to work, both through its effects on these symptoms and through its side effects. Several studies have documented the variability in physicians’ prescribing behaviour, including in the prescribing of antipsychotics and related medication (Ito et al. 2005; Rosenheck and Leslie 2003; Young et al. 2006). Relatively few studies, however, have compared medications in terms of their ability to help people receiving Individual Placement and Support services. One study that sought to do exactly that compared two atypical antipsychotics (olanzapine and risperidone) with unspecified typical ones. At the end of the nine-month observation period, the two groups’ outcomes were not statistically different. The observational study design and limited sample (ninety subjects) preclude a definitive conclusion (Bond et al. 2004). Nonetheless, optimization of prescribing for clients of Individual Placement and Support programs might increase the effectiveness of such programs. More generally, improvement in the overall management of psychiatric and co-morbid illnesses, including physical illnesses and substance-use disorders could enhance the effectiveness of Individual Placement and Support programs (Drake and Bond 2008). A study aiming to test this hypothesis directly is currently under way in the United States (Frey et al. 2008). For a fuller discussion of these issues, the reader is referred to (Drake and Bond 2008).

Conclusions and Policy Implications In the modern context of emphasis on recovery, improving access to employment for people with severe mental illness has become widely acknowledged as essential. If competitive work is viewed as

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particularly conducive to recovery and intrinsically more desirable than non-competitive employment, then experimental research now clearly also demonstrates that the Individual Placement and Support model is a more effective means of helping people obtain competitive jobs and accumulate hours and earnings from them than are the alternatives against which it has been tested. At the same time, it is clear that Individual Placement and Support is not effective for all clients. Research is currently underway, along several lines, to improve the effectiveness of Individual Placement and Support programs, partly through more successful implementation and partly by improving on the model itself. While the current principles of the Individual Placement and Support model are likely to be maintained in any future evidence-based supported-employment model, partly on the basis of evidence and partly (as in the case of the principle of zero exclusion) on ethical grounds, the evidence and arguments in support of some other features of the Individual Placement and Support model that the Individual Placement and Support fidelity scale measures but that are not implied by its principles are not as strong, and some of those features could ultimately be modified. New components could also be introduced in the light of research findings, for example, with regard to cognitive training. These unanswered questions notwithstanding, the evidence to date clearly supports significant expansion of the Individual Placement and Support model in its current form. A monograph on the applicability of the Individual Placement and Support model to Québec issued by the Agence d’Évaluation des Technologies et Modes d’Intervention en Santé (forthcoming) suggests, based on a synthesis of several estimates in the literature, that providing approximately 60 Individual Placement and Support places per 100,000 population would be a reasonable initial target (Agence d’Évaluation des Technologies et Modes d’Intervention en Santé Forthcoming). This translates to approximately 20,000 places across Canada. A careful estimation of the cost of such a program expansion across Canada is beyond the scope of this chapter. The same monograph, however, estimates that the cost per place in an Individual Placement and Support program, including vocational adviser wage costs and expenses such as travel and phones, but not occupancy costs or agency overhead costs, would be in the order $4,450 per year. The same monograph estimates on this basis that a deployment of 60 Individual Placement and Support places per 100,000 population

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would cost about half the current expenditures in the province of Québec, through both the Ministry of Health and Social services, and the Ministry of Employment and Social Solidarity, on its current vocational rehabilitation programs for people with severe mental illness (including, for example, sheltered workshops, day-treatment centres and affirmative businesses). Thus, given opportunities for replacing existing programs with Individual Placement and Support, the cost of a deployment of Individual Placement and Support on this scale does not appear prohibitive. To what extent should more traditional programs be maintained, however? As previously indicated, experimental evidence to date suggests that even if such programs are made available, employment rates are not likely to be significantly higher than if only competitive options are offered. Such options may, however, prove more advantageous during economic downturns: while some early evidence suggested that the overall unemployment rate had little impact on the effectiveness of Individual Placement and Support programs (Catalano et al. 1999), more recent studies tend rather to the conclusion that client employment rates tend to be lower where the overall unemployment rate is higher (Becker et al. 2006; Burns et al. 2007). That consideration aside, we do not know to what extent the jobs that certain types of non-competitive businesses, such as consumerrun businesses, provide for clients may be beneficial in comparison with competitive jobs. Further research is needed on this score, research encompassing also an economic dimension: to the extent that non-competitive opportunities require government subsidies, are the benefits from providing them worth their additional cost? Until such research is carried out, it seems clearly preferable to focus on closing programs such as day-treatment centres, which clearly do not seem as beneficial for clients. One particular organizational difficulty that further development of Individual Placement and Support poses is that Individual Placement and Support programs potentially fall under the responsibility either of health and social services or of ministries responsible for helping people return to work. Who, then, should be assigned the responsibility for organizing and managing them? It is perhaps best to allow such programs to develop in multiple settings and contexts. What is important is that they be adequately funded and well managed. To facilitate this goal, provincial (or in some parts of the country, such as the Atlantic provinces, regional) technical assistance

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centres should be set up. Such technical assistance centres, modelled on counterparts in a few US states such as Ohio or Kansas, could assume the combined functions of (1) identifying sites ready to implement an Individual Placement and Support program, (2) providing directly and/or facilitating the initial and continuous training that such programs need, (3) monitoring outcomes, and (4) representing the programs as a whole in provincial-level discussions concerning regulations (for example, regulations concerning disability benefits) and funding. Another policy, one that is being pursued in the United Kingdom and that could be pursued in Canada as well, is insisting that health and social service employers in particular, and public sector employers more generally, give preference in hiring decisions to people with disabilities, including people with severe mental illness, when other factors are equal (Seebohm and Grove 2006). Finally, it is worth noting that Canada offers, compared to most other industrialized countries, an especially favourable context for the introduction of high-performing supported-employment programs, for three reasons: (1) unlike the United States, it offers guaranteed health care coverage regardless of income or employment status (although coverage for medications varies from province to province); (2) its employers face less constraining labour laws than those of many continental European countries; and (3) its unemployment rates are typically lower than in many European countries. In conclusion, while the Individual Placement and Support model does have limitations, at present it appears to offer an effective and relatively inexpensive means of helping many people with severe mental illness make progress toward the attainment of better community integration and ultimately, a more satisfying life. Numerous research efforts currently under way appear likely to help further increase its effectiveness.

Note Through the sharing of many insights on the supported employment literature, Bob Drake, Debbie Becker and Gary Bond, of the Dartmouth Psychiatric Research Centre, and Daniel Gélinas of the Centre de recherché Fernand Séguin in Montreal, have been singularly helpful. Nicole Lahaie and Marie-Sylvie St-Pierre, supervisors of the IPS program at the

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Douglas Institute, along with vocational advisors in the program, have helped me see how supported employment can work in a Canadian setting, and they have shared many stories that have helped to make the principles and practice of supported employment come to life. Marc Corbière, of the University of Sherbrooke, has challenged and thus helped to sharpen my thinking. I have also benefited from conversations with several people and groups in the United Kingdom, notably with Bob Grove, Miles Rinaldi, Geoff Shepherd and others associated with the Sainsbury Center for Mental Health, and with Justine Schneider at the University of Nottingham. An anonymous reviewer made some helpful suggestions for improvement. I am responsible for all remaining errors or imbalances in the chapter.

Contributors

joan bishop is the CMHA North Simcoe ACT team psychiatrist, professor emeritus at the University of Western Ontario, a consultant at Orillia Soldiers Memorial Hospital, and a member of ACT advisory committees for both the Ontario and the British Columbia health ministries. Before coming to Orillia in 2007, she was associate professor of psychiatry at the University of Western Ontario and then at the University of British Columbia, with a major focus on improving services for persons with severe mental illness. Since completing her masters degree in epidemiology and biostatistics in 2002, she has obtained funding for mental health services research and is currently a co-principal investigator on a CIHR grant to study therapeutic processes in assertive community treatment. Erika Braithwaite completed her undergraduate degree in psychology at Concordia University. She is currently a graduate student in psychology at the University of Montreal. Her research interests include psychopathy and the link between severe mental illness and criminality, as well as risk assessment in civil psychiatric settings. Gilles Côté is a criminologist and psychologist and professor at the Université du Québec à Trois-Rivières and associate professor in the Department of Psychiatry at the Université de Montréal and the Université de Sherbrooke. He is also director of the research center at the Institut Philippe-Pinel de Montréal. Anne Crocker, PHD, is a forensic mental health researcher, director of the Services, Policy and Population Health Research axis of

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the Douglas Mental Health University Institute and assistant professor in the Department of Psychiatry, McGill University. She is also a member of the Mental Health and Law Advisory Committee of the Mental Health Commission of Canada. Dr Crocker’s research in forensic mental health has examined the rates and psychosocial correlates of aggressive behaviour, violence, and criminality in persons with a severe mental illness or intellectual disability. She has also explored criminal justice mechanisms for dealing with individuals with severe mental illness or an intellectual disability (e.g., criminal responsibility, review board decision making, psychiatric advance directives, and diversion programs). She has a special interest in risk assessment and management, as well as the strategies needed to implement them. Cheryl Forchuk, RN, PHD, is professor in the School of Nursing at the University of Western Ontario and professor in the Department of Psychiatry, Schulich School of Medicine and Dentistry. She is also an assistant director for the Lawson Health Research Institute, the research arm of the London hospitals. Dr Forchuk’s research has focused on persons with mental illness, and she has published widely on topics that include housing and the mentally ill, transitional discharge, and peer support. Jill Grant is assistant professor in the School of Social Work at the University of Windsor and Director of the Community Based Research and Development Centre. She works with mental health service users and service providers to conduct research in the areas of community mental health services, relationships between service users and service providers, consumer-survivor participation, and social exclusion. Jill teaches social-work theory and practice courses and provides extensive amounts of training in various practice areas to professionals. Virginia Aldigé Hiday, PHD, is professor, Department of Sociology, North Carolina State University, with research interests in law and psychiatry, particularly outpatient civil commitment, mental health courts, and violence, victimization, and criminalization among persons with severe mental illness. Besides being a co-investigator on the North Carolina Mental Health Study of Outpatient Commitment, she has been principal investigator of two other NIMH-funded projects on

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civil commitment, resulting in numerous publications with important policy implications. Early studies focused on court proceedings, judge’s decisions, the role of counsel, and the nature of the evidence of dangerousness. Subsequent studies focused on subjective experiences and outcomes of respondents engaged in civil commitment. Her work has been used in formulating policy in Canada and the United States and by governments overseas. Dr Hiday serves the UNC-Duke Mental Health Services Research Training Program as a seminar presenter and research consultant. Eric Latimer, PHD, is associate professor in the Department of Psychiatry at McGill University and since 1996 has been  a research scientist at the Douglas Mental Health University Institute in Montreal. A health economist by training, he has a particular interest in evidence-based practices for people with severe mental illness. In particular, he has written on the economics of assertive community treatment and supported employment. He also led the first trial of Individual Placement and Support (IPS) conducted in Canada and is the author of a just-released monograph published under the auspices of the Québec Health Technology Assessment Agency (Agence d’Évaluation des Technologies et Modes d’Intervention en Santé) on the applicability of the IPS model to Québec.  Steve Lurie is currently the executive director of the Canadian Mental Health Association (CMHA), Toronto Branch, a post he has held since 1979. A principal author of the Graham Report, Building Community Support for People, he conducted the 1992 snapshot of community mental health programs in Ontario that established a common data set for client characteristics and outcomes in mental health services. He also provided technical assistance to the Senate Committee report Out of the Shadows at Last: Transforming Mental Health and Addiction Services in Canada. Mr Lurie now chairs the Service Systems Advisory Committee for the new Mental Health Commission of Canada and was recently awarded the CMHA’s C.M. Hincks award for national leadership in mental health. He is also adjunct professor in the Faculty of Social Work at the University of Toronto. Beth Mitchell, PHD, C.Psych. is the director of the Mental Health Care Program at the London Health Sciences Centre, a large acute program serving the lifespan through in-patient and outpatient services.

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She also holds appointments as associate professor at the University of Western Ontario in the Departments of Pediatrics, Psychiatry, and Psychology. Dr Mitchell has served on a number of local and provincial bodies related to mental health and is an investigator with the Consortium for Applied Research and Evaluation in Mental Health (CAREMH), focusing on the impact of system change, program development, evaluation, and knowledge transfer. Geoffrey Nelson is professor of psychology in the Community Psychology program at Wilfrid Laurier University. He served as senior editor of the Canadian Journal of Community Mental Health, was the recipient (with the Canadian Mental Health Association/ Waterloo Region Branch) of the Harry McNeill Award for Innovation in Community Mental Health from the American Psychological Foundation, and was university research professor at Wilfrid Laurier University. His research and practice has focused on community mental health programs and supports for people with serious mental illness (including studies of supportive housing and self-help groups and organizations) and community-based prevention programs for children and families. Ross M.G. Norman, PHD, C.Psych. is a psychologist and professor in the Department of Psychiatry and the Department of Epidemiology and Biostatistics and adjunct professor in the Department of Psychology at the University of Western Ontario. His recent research has focused on early intervention in psychotic disorders – including studies of pathways to care for patients experiencing their first episode of psychosis, community intervention to reduce treatment delay for psychosis, the impact of early intervention on treatment outcome, evaluation of the effectiveness of specific psychosocial interventions for psychotic disorders, the effect of social support on treatment outcome, and the family experience of psychosis, as well as work related to the basic nature of psychopathology in psychosis. Dr Norman and his colleagues have also become increasingly involved in research on the stigmatization of mental illness. Richard O’Reilly was born and raised in Northern Ireland. He studied medicine at Trinity College Dublin, training as a specialist in internal medicine before undertaking psychiatric training in Dublin and in London, Ontario. He has worked as a consultant psychiatrist in the

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Republic of Ireland and in Saskatchewan and Ontario and currently works with a rural assertive community treatment team. Dr O’Reilly is professor of psychiatry at the University of Western Ontario and at the Northern Ontario School of Medicine. His academic interests are mental health law and genetic causes of schizophrenia. Stephen A. State, PHD, is the coordinator of the Consortium for Applied Research and Evaluation in Mental Health, a network of heterogeneous stakeholders in community mental health services whose purpose has been to expand capacity in research and evaluation in this field. He has been a co-investigator on a number of projects in criminalization and forensic mental health services, and he participated in the committee work that led to the development of a Mental Health Court in London, ON. Previously, he taught the history of political thought in the Department of Political Science at the University of Western Ontario for some twenty years. He is currently an adjunct research professor with the Population and Community Health Unit in the Department of Family Medicine, University of Western Ontario. Raj Velamoor, MB, DPM, MRC Psych, FRC Psych (U.K.), FRCP (Can.) trained in both India and England, immigrating to Canada in 1984, where he was professor of psychiatry at the University of Western Ontario (UWO) and director of emergency psychiatry  at the London Health Sciences Center, Ontario, until 2003. He was awarded the Fellowship of the Royal College of Psychiatry (U.K.) in 2003 and was on faculty at the University Hospital of Cornell and Columbia, New York, from 2003 to 2005. He has also worked as consultant psychiatrist in New Zealand and Bermuda. His research in neuroleptic malignant syndrome is internationally recognized, and his publications include a monograph on the interface between primary care and psychiatry. He is currently professor emeritus at the University of Western Ontario and lives in Toronto. Evelyn R. Vingilis, PHD, C.Psych., is a registered psychologist and director of the Population and Community Health Unit and professor in the Departments of Family Medicine, and Epidemiology and Biostatistics at the University of Western Ontario and adjunct professor in the School of Psychology and Counselling, Centre for Accident Research and Road Safety-Queensland, the Queensland

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University of Technology, Australia. She has clinical, management, and research experience with a particular focus on program evaluation and knowledge transfer. Her research interests are in mental health services, road safety, and at-risk youth. She has taught courses in program and policy evaluation to graduate students in epidemiology, family medicine, nursing, psychology, and public administration. Bob Wales received his MSW from the University of Windsor and has worked in hospital and the community as a case manager, program coordinator, consultant, and educator. Bob has provided case management training to hospital-based staff preparing for work in community-based services. He also promoted PSR education at the community college level as chair of the Ontario PSR Education Committee and has been a leader in ACT team development. Bob is an original member of the Ontario ACT Technical Advisory Panel (TAP-1998) and is past chair of this group. He has been employed by the Ontario health ministry to provide orientation and support to new ACT teams, and he also worked as a subject matter expert for the provincial Community Mental Health Common Assessment Project, in which he prepared curriculum and training materials for a multi-site, province-wide pilot. Currently, he provides recoveryfocused consultation, training, and technical assistance for eleven ACT teams and the Psychosis Program in-patient units sponsored by St Joseph’s Health Care London. Heathcote W. Wales, J.D. Professor Wales has taught at Georgetown University Law Center since 1971, specializing in constitutional law, criminal law, law and psychiatry, and law and social science. He has served as consultant to numerous government and professional task forces and has written principally in the field of mental health law. Most recently, he has turned his attention to mental health courts and to outcome studies in a felony court in Bonneville County, Idaho, and a misdemeanor court in Washington, DC.

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Chapter two Bahn, A.K. 1965. An Outline for Community Mental Health Research. Community Mental Health Journal 1:23–8.

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Index

Aalto, D.R., 226 Abram, K.M., 85–8 Abramson, M.F., 81–2 Adler, D.A., 167, 174 affirmative businesses, 212 Agence d’Évaluation des Technologies et Modes d’Intervention en Santé (Québec), 229 Alcoholics Anonymous, 140 alienists, 18 Alisky, J.M., 116 Allebeck, P., 96 Allen, M.H., 48 Allen, N.B., 117 Allness, D.J., 39, 182, 184–5, 190, 203 Almvik, R., 107 Alverson, M., 221 Ambady, N., 125 American Medico-Psychological Association, 23 Amir, Y., 120 Anderson, H.S., 97 Angermeyer, M.C., 88, 94, 97, 115, 117, 120, 122, 124, 155–6 Anthony, W., 198–9, 208

Anti-Social Personality Disorder (ASPD), 87–8 Appleby, L., 99 Arboleda-Florez, J., 83–4, 88, 95, 100 Arfken, C.L., 65 Arkar, H., 119–20 Arseneault, L., 95–6 Aseltine, R.H., 50 Assertive Community Treatment (ACT), 39, 52, 182–210; challenges in analysis of, 196–8; Cochrane review of, 186, 200–1; co-morbidities and, 193; costing and economic studies of, 187–8; developmental disability and, 193–8; efficacy and effectiveness of, 185–6; ethical criticism of, 204; external context and, 204; face-to-face contacts and, 191; fidelity of implementation of, 200–3; forensic involvement and, 193–8; homelessness and, 193–8; Index of Fidelity to ACT, (IFACT), 201; Intensive Case Management vs, 186; Local Health Integration Networks

348

Index

and, 202; Netherlands studies of, 189–92, 210; origins of, 182–3; outcomes of, 188–98; program features of, 183–4, 203–4; recovery and, 208–9; research on how ACT works, 198–204; substance abuse and, 193–8; syntheses and meta-analyses of, 186–7; target population of, 184–5; theories of implementation of, 200–3; theory of cause and effect regarding, 198–200; UK studies of, 188–91 Association of Medical Superintendents of Institutions for the Insane, 23 asylums, 18–24; Beauport, 21; Bicetre, 19; Toronto, 21; York, 18 Augimeri, L.K., 107 A-Way Express, 141 Badamgarav, E., 162, 180 Badcock, B., 117 Bailey, E.L., 217–18 Balke, A., 181 Banks, S.M., 59, 85–6 Baranoski, M.V., 102 Bardi, A., 126 Barker, C., 140 Barnes, D., 46, 180 Barnes, J., 33, 41, 43, 47, 52 Barnsteiner, J.H., 180 Baronet, A. 186, 198 Barrow, S., 143 Bartlett, P., 16 Bassuk, E.L., 98 Baumann, E., 119–20, 124 Baumeister, R.F., 117, 127 BCMOH, 203 Bebbington, P., 55 Beck, C.A., 115

Becker, D., 211, 216–19, 221–3, 226–7, 230 Bedell, J.R., 217 Beers, C., 23; A Mind That Found Itself, 23 Belenko, S., 43 Bell, M., 211, 227 Bender, W.S., 193 Bessenoff, G.R., 127 Bhui, K., 143 Bibeau, L., 83 Bickman, L., 36–7, 39–40, 52 Biernat, M., 125–6 Biglan, A., 41, 44–5, 52 Binder, R.L., 58, 65 Birchwood, M., 116 Bishop, J., 36–7, 39–40, 43, 46–8, 50–2, 196, 207 Bittner, E., 82 Bjorklund, R.W., 203 Blaauw, E., 84 black box, 36, 42, 52 Bland, R., 96, 162–3, 174–6 Blasius, J., 109 Blom, D.J., 26 Bloom, H., 98–9, 107 Blumenfield, M., 179 Bodenhausen, G.V., 118 Bogenberger, R.P., 97 Bond, G.R., 39, 184–7, 190, 194, 199–200, 202, 205, 211, 214–20, 223, 225–8 Bonnie, R.J., 97 Bonta, J., 85, 87, 99, 103, 108 Borum, R., 83, 86, 88–9, 107–8 Borzecki, M.A., 82 Bosker, R., 48, 50 Bourgeault, I., 162 Bower, P., 162, 168, 170, 174–6 Bowl, R., 143 Bowman, C.H., 125

Index

Boyce, M., 220 Boyle, G., 132 Boyle, M.H., 48, 50 Braden, J., 36 Bradford, W.D., 116 Brekke, J.S., 48, 50, 80, 82 Brennan, P.A., 95–6 Bright, J.A., 115, 117 Brinded, P.M., 96 Brink, J.H., 84–5, 96 British Columbia Ministry of Health Services, 184, 203, 209 British Royal College of Psychiatrists, 119 Broadbent, M., 64 Broner, N., 92 BrØset Violence Checklist, 107 Brown, C., 148 Brown, J.B., 163 Brown, R., 125 Brown, T.E., 24 Brown, T.J., 19 Brown, V.B., 98 Bruce, M.L., 80 Bryant, D., 37 Bryant, K.J., 98 Bryk, A.S., 48, 50 Burgess, P.M., 71, 73–4 Burkell, J., 36 Burns, T., 47, 211, 226, 167, 174, 190–1, 201, 204, 217, 219, 223, 230 Burstow, B., 130 Burti, L., 141 Burtless, G., 41, 52 Byrne, P., 124 Callaghan, P., 120 Calsyn, R.J., 199 Campbell, D.T., 43–4 Campbell, J., 130

349

Canada Housing, 152 Canada Pension Plan, 154 Canadian Collaborative Mental Health Initiative, 162, 180 Canadian Journal of Mental Health, 4 Canadian Mental Health Association, 135, 158 Canadian National Committee for Mental Hygiene, 25 Canvin, K., 75 Caplan, G., 29 Capponi, P., 143 Caracelli, V.J., 34 Cardinal, C., 101 Carey, R.G., 36–8, 43–5, 52 Carling, P.J., 150, 157 Carlson, L.S., 138 Carpenter, D., 48 Carpenter, J., 40, 52, 180 Carpenter, L.L., 57–8 Carroll, A., 104 Carson, J., 185 Calsyn, R.J., 204 Caspi, A., 88, 93n4 Castro, F.G., 43 Catalano, R., 57, 65, 67, 230 Catty, J., 42, 47 cause: assumption of, 38; attribution of, 35–7, 41; complexity of, 35, 38, 40; effects of, 44; links, 36; models, 37–9, 46; pathways, 37–8; processes, 36–7 CCAR (Colorado Client Assessment Record), 197 Centre for Assessment & Research on Mental Health and Addictions (CARMHA), 210n Chaimowitz, G., 104 Chamberlain, R., 47 Chamberlin, J., 130–1, 139

350

Index

Chan, K.F., 119–20 Chandler, D., 188, 217, 222 Changing Minds campaign, 119 Chaput, Y.J.A., 59, 66 Chen , H.T., 34, 36–8, 52 Chiang, Y.P., 47 Chicago Thresholds ACT project, 194 Chilvers, R., 158 Chinman, M.J., 138 Choe, J.Y., 94 Christy, A., 69 Chu, D., 30 Chue, P., 203 Church, K., 135–6 Churchill, R., 70, 77 Cialdini, R.B., 125 Cicchetti, D., 134 CIHI, 163 Claassen, C.A., 57, 59 Clark, R.E., 25, 80, 83, 85 Clarke, D., 161 Clarke, D.E., 57–8, 60, 67 Clarke, G.N., 139, 199, 204 Classification of Violence Risk (COVR), 105 Clement, J.A., 98 client/consumer, 48 clubhouses, 212 CMHEI (Canadian Mental Health Evaluation Initiative), 53 Cochrane: Cochrane lecture, 41; review of counselling in primary care, 167; review of housing, 158 Cockburn, L., 187 Cohen, S., 116 Coldwell, C.M., 193 collaborative mental health care, 160–81; case management and, 166, 175; challenges of meth-

odology, analysis, and metaanalysis, 172–7; clinical nurse specialists and, 166; common client records and, 167; consultation liaison and, 165–6, 169, 178–9; counselling and, 167; definitions of, 163; disease management programs and, 165; historical obstacles to, 161–2; integrated treatment and, 168; in primary care, 160–81; quality improvement programs for depression and, 170–2; shared care and, 164; systematic reviews of, 164–5, 174–7 Commission on Hospital Service, American Hospital Association, 28 Community Mental Health Centers, 27, 30 Community Mental Health Journal, 4 community treatment orders: “mandate drift” and, 69; “revolving door” patients and, 69; “thank you theory” and, 75; ACT and, 70; Canadian provincial variation in, 68; case-controlled studies and, 71; coercion and, 75; controversy about, 70, 77; effects and effectiveness of, 5, 7–8; forms of, 76; hospitalization and, 73, 77–8; international instances of (US, Australia, New Zealand, Israel, Scotland and UK), 69; mirror image design and, 71; New York City and North Carolina RCT trials of, 72, 74; outcomes of interest and, 72, 74, 77–9; post hoc analysis of, 73–4; RCT trials of, 72, 77–8; reasons for,

Index

69; research studies of, 71; subjects’ diagnoses and, 75; subjects’ views of, 75; suitable subject matching in studies of, 71–2, 77– 8; treatment adherence and, 73; treatment non-adherence and, 70; vs conditional discharge, 68 Compton, M., 56 Connor, H., 143 Conolly, J., 19 Consortium for Applied Research and Evaluation in Mental Health (CAREMH), 6, 114n2 Constantino, V., 140, 143 Consultation Liaison in PrimaryCare Psychiatry (CLIPP), 166 consultation liaison. See collaborative mental health care consumer participation: agency and program governance and, 137–8; ameliorative change and, 132–3; anti-psychiatry movement and, 130; barriers to, 143–4; community mental health organizations and, 138–9; consumer-run organizations and, 40–1; definitions of, 129; evidence-based practices and, 131; historical background of, 130; participatory action research and, 142–3; policy and planning and, 136–7; rationale for, 30; research and, 142–3; self-help groups and, 139–40; self-help movement and, 130; strategies to overcome barriers to, 143–4; transformative change and, 133–5; types of, 35; values and, 131 Consumer/Survivor Initiatives, 141 consumer-run businesses, 212

351

Cook, S., 174 Cook, T.D., 43–5, 52 Cooke, D.J., 84 Cooksy, L.J., 37, 52 coping techniques, 121, 123, 127 Copolov, D.L., 176 Corbière, M., 220, 232 Cordray, D.S., 34, 36, 41, 47–8, 50, 53 Coristine, R., 46, 60 Corrado, R.R., 84, 86–9 Corrigan, P.W., 5, 34, 95, 112, 115–21, 124, 127, 132–3, 141, 213, 216, 221 Cosden, M., 39, 194 Côté, G., 86, 96, 101, 108–10 Cousins, J.B., 36–7, 39, 46, 52, 198 Couture, S.M., 118, 124 Cox, D., 167 Crandall, D.S., 125 Craven, M.A., 162–3, 174–6 Crawford, M.J., 143 criminalization of mental illness: explanations and contributing causes, 80; and incarceration, 84; and police arrest, 82–3, 179; and psychopathy, 87–8; and substance misuse, 85; and types of offences, 88–90; and violence by persons with mental illness, 84–92 Crisp, A.H., 119, 123, 155 Crocker, A., 85, 87 Crown, W.H., 51 Crutcher, H.B., 26 Csiernik, R., 155 CTO. See community treatment order Cuddeback, G.S., 195 Cuellar, A.E., 90 Cuffel, B.J., 99

352

Index

Cullen, F.T., 156 Curtis, L., 46 Daffern, M., 106–7 Dahle, K.P., 106 Damsa, C., 59, 65 Danesh, J., 84, 87 Daniel, A.E., 96 Daniels, N., 143 Dartmouth ACT Scale (DACTS), 190, 197, 200–1, 206 Dartmouth Psychiatric Research Center, 216, 228 data: hierarchical, 48; longitudinal, 48; nested, 48; non-independent, 50 Datta, L.-E., 34 Davidson, L., 138–9 Davidson, M., 122 Davies, M.R., 123 Davis, M.M., 49 Davis, S., 26 Day, D.M., 94 days of stay, 47 day-treatment centres, 212 De Oliveira-Souza, R., 87 De Veau, L., 71 Dean, K., 97 Deane, M.W., 83 Dear, M.J., 156 Deegan, P.E., 5 Defeat Depression, 119 Dehejia, R.H., 51 Delva-Tauiliili, J., 119–20 DeMartino, R., 50 Desai, R.A., 85, 88, 89 Desforges, D.M., 120 designs: case control, 43; comparison groups, 44–5; experimental, 35–6, 40–2, 49, 50–3; inter-

rupted time series (ITS), 43–5, 53; multi-level, 50; non-equivalent comparison group, 43, 45, 53; observational, 50; prospective cohort, 43; quasi-experimental, 35, 40, 43, 49, 51, 53; regression discontinuity (RDD), 43–4, 53; short time series (e.g., ABAB), 44; single-level, 50 Deuchar, N., 201, 209 Dewa, C., 37, 39, 46, 52 Diamond, B., 143 Diamond, M., 104 Dietrich, S., 120 Dincin, J., 221 disease management programs, 165 Ditton, P.M., 84 Dix, D., 19, 21 Dixon, L.B., 39, 185 Douglas, J., 21 Douglas, K.S., 85, 104, 106, 109–10 Dovidio, J.F., 120, 125, 127 Dractu, L., 56 Draine, J., 81, 85, 138–9, 147, 151, 194, 211 Drake, R.E., 92, 96, 98, 147, 151, 155, 180, 185, 193, 202, 216– 18, 221–2, 225–7 Drebing, C.E., 211 Dreezer, S., 68 Drug Attitude Inventory, 197 Druss, B.G., 4, 42, 116 Duncan, T.E., and S.C. Duncan, 44–5 Dunn, J.R., 146–7 Durbin, J., 149 Dutch Functional ACT, 210 Dvoskin, J.A., 104–5

Index

Dynamic Appraisal of Situational Aggression (DASA), 107 Earl, L.M., 36–7, 46 Early Assessment Risk List for Boys (EARL-b), 107 Early Assessment Risk List for Girls (EARL-g), 107 Eckert, A., 143 Edginton, B., 25 Edwards, B., 119 effectiveness, 40, 42–3 efficacy, 40–3 Eker, D., 119–20 Eklund, M., 214 Emergency Department (ED). See hospitalization Emerick, R.E., 140 employment. See supported employment Empowerment Scale, 197 Endler, N.S., 196 Engel, G.L., 162 Engel, R.S., 83, 88–9 Epidemiological Catchment Area Study (ECA), 95 EQOLISE study, 225 Erb, M., 96 Erickson, D.H., 116 Eronen, M., 96–7 Eshleman, A., 125 Estroff, S.E., 96, 120 evaluation: economic, 34, 46, 51; efficiency, 34; fidelity, 37, 39; formative, 34, 37; implementation, 34, 37, 51; monitoring, 34, 37; outcome, 34–6, 46, 48, 52–3; process, 34, 37, 39, 40, 46, 51; program rationale, 34; summative, 34 Evans, L., 220

353

Everett, B., 131–5 Evers, S.M.A.A., 46 Eynan, R., 151 Farina, A., 115–16, 120 Farrell, S.J., 68 Fazel, S., 84, 87 Feliner, D., 116 Felix, R., 29 Fenton, Dr Wayne, 95 Fernandez, G.A., 71 Fishbein, M., 125 Fisher, W.H., 84–6, 89–92 Fixsen, D.L., 224 Fletcher, J., 174–6 Fletcher, T.D., 180, 193, 202 Fonagy, P., 33, 41–2, 53 Forchuk, C., 40–1, 48, 151, 156–9 Forensic ACT teams, 194 Forensic Intensive Case Management, 195. See also Assertive Community Treatment Foucault, M., 12, 29, 130–2, 135 Foulds, G., 143 Foy, R., 39, 52 Framework for Support, 136 Franx, G., 34, 39, 52 Freedman, A.M., 162 Freeman, E., 37 Frey, W.D., 228 Friedrich, R.M., 151 From Madhouse to Our House, 143 Fuhrman, B., 52 Fuller-Thomson, E., 146 Gaebel, W., 119–20, 123–4 Gaertner, S.L., 125 Galanter, M., 98 Galletly, C.A., 120 Gallie, W.B., 14

354

Index

Gardner, W., 103–4 Garrett, K.E., 38, 52 Gawronski, B., 118 Gehrs, M., 196 Geller, J.L., 69, 71, 155 Gensichen, J., 162, 180 George, L., 186, 201 Gerber, G.J., 186, 198, 203 Gerson, S., 98 Gervey, R., 217 Ghaemi, S.N., 162 Gibbons, R.D., 48–50 Gibbs, A., 75 Gilbody, S., 162, 164–5, 174–6, 181 Glancy, G.D., 104 Glanz, K., 36 Glasscote, R.M., 29 Glaze, L.E., 84 Goeree, P., 4 Goffman, E., 29–30, 116, 120 Gold, M., 217 Gold, P.B., 216, 222 Goldfinger, S.M., 151 Goldstrom, I.D., 144 Gollaher, D., 19 Gomory, T., 204, 207 Gonzales, J., 165, 169, 177 Goodear, J., 120 Gottlieb, P., 96 Gowdy, E.L., 222, 225 Graham, S., 50 Graham Report, 136 Grann, M., 106, 108 Grant, J., 137–9, 142–3 Green, L.W., 42 Green, T.M., 83, 89 Greenacre, M.J., 109 Greenberg, G.A., 85 Greene, J.C., 34 Greenland, K.J., 49

Greenstein, T., 127 Grembowski, D., 36–8, 43–5 Grevatt, M., 106 Griffiths, K.M., 123, 126 Griss, 223 Grob, G., 4, 23, 26, 28–9 Groff, A., 72–4 GROW, 130 Grube, J.W., 127 Gruen, R., 164 Grumbach, K., 176 Grunes, S., 120 Gudjonsson, G.H., 96 Guo, S., 66 Guthrie, E., 46 Guyatt, G.H., 33, 42 Guynan, K., 124 Hackman, A., 209 Haddock, G., 126 Haggarty, J., 163, 166, 176 Haghighat, R., 117 Hall, G.B., 148, 151–2, 157 Hall, R.C., 99 Hamilton, M., 17 Happell, B., 56, 59, 64, 137 Hardiman, E.R., 131, 143 Hare, R.D., 109 Harmon, K., 166, 176 Harpole, L.H., 168 Harre, N., 120 Harris, G.T., 87, 105, 108, 111 Harris, R., 147 Hart, S.D., 105, 107–8, 111 Hartford, K., 40, 162 Hartley, D., 163 Harvey, C.A., 166 Haslam, D., 163, 166, 176 Hawthorn, L.R.L., 38 Hayward, P., 115, 117

Index

Heagerty, P.J., 49 Hebl, M.R., 120, 125 Hedrick, S.C., 162, 168, 173 Heilbrun, K., 104–5 Hemmens, C., 115 Henggeler, S.W., 40 Herinckx, H.A., 185, 199 Herman, D.B., 84 Hickman, M., 164 Hiday, V., 72–4, 94, 96 Higgins, E.S., 163 Hincks, C., 25 Hinshaw, S.P., 127, 134 Historical Clinical Risk Scheme 20 (HCR-20), 106 Hoagwood, K., 42 Hobbs, C., 50 Hoch, J., 46 Hodge, S., 137 Hodges, J.Q., 143 Hodgins, S., 85, 87–8, 95–7, 100, 102, 108–9, 111 Hoekstra, E.J., 220 Hoenig, J., 17 Hogg, M.A., 125 Hohmann, A.A., 36, 41 Holden, E.W., 52 Holley, H.L., 83 Holloway, F., 185 Holtgraves, T., 117 homelessness. See housing and mental health Homes for Special Care, 149 Horwitz, A.V., 90 hospitals: Bellevue Hospital, 23; Danville State Hospital, 27; Manitoba Psychopathic Hospital, 25; Maudsely Hospital, 16, 22; psychopathic hospitals, 23–8; Pilgrim State Mental

355

Hospital, 26; Rockland State Mental Hospital, 26, 32n3; St Thomas Mental Hospital, 26; Veterans Hospital, 30 hospitalization: admissions to hospital following emergency department (ED) visits, 65; behavioural health units in ED, 65; coordination with other services by ED, 56, 65, 66; expectations about ED, 58; improper vs. appropriate use of ED, 56–7; providers’ vs clients’ views of visits to ED, 57–8; psychiatric presentation to ED, 58; treatment in ED, 65; triage for psychiatric presentations to ED, 60–4, 66–7; typical groups using ED, 59; use in evaluations, 47 Hotopf, M., 73 Hough, W.G., 45, 69, 74 Hoult, J., 185, 187 House, A.O., 48, 143 housing and mental health: approaches to (custodial, supportive, supported), 149–51; best practices regarding, 157–8; homelessness and, 147–8, 151; importance to persons with mental illness, 147; income support and, 153–5; key constituents of, 146–7; peer support and, 150; perceptions regarding, 148; policies regarding, 152–3; preferences regarding in persons with mental illness, 151–2; societal attitudes and, 155–6 Howard, L.M., 216–17 Howe, A., 174 Howells, K., 107

356

Index

Hucker, S., 105 Hudson, T.J., 116 Hugo, M., 65 Hulchanski, J.D., 146 Humphreys, K., 140 Humphreys, M.S., 97 Hunkeler, E.M., 166 Hunt, A.M., 69, 71 Hurd, H.M., 17, 20, 32 Hutchison, P., 129–30, 134–5 Huxley, P., 119–20 Hwang, S., 146 Hyde, P.S., 96 Iczkowski, A., 116 Illingworth, P., 180 indicators of positive outcomes, 47 Individual Placement and Support. See supported employment insurance coverage, 176 Intensive Case Management. See Assertive Community Treatment International Covenant on Economic, Social, and Cultural Rights, 146 involuntary treatment, 179. See also community treatment orders Isaac, S., 37, 44–5 Ito, J., 203 Ito, H., 228 Jackson, A.J., 27, 29 Jackson, C.L, 180 Jacobi, F., 3 Jacobson, N., 46 Jahr, E., 112 James, D.J., 84 Janzen, R., 141 Johnson, B.T., 120 Jones, K., 16–17, 22 Jones, Maxwell, 31

Johnson, S., 116 Jonikas, J., 112 Jorm, F., 123 Judd, C.M., 124 Julian, D.A., 37, 39 Junginger, J., 84–5, 91 Jussim, L., 124 Kaas, M.J., 180 Kahn, M.W., 58 Kallgren, C.A., 125 Kalucy, R., 57 Kaplan, R.J., 69 Kaplan, S.A., 38, 52 Kates, N., 162–3, 166–7, 174 Kathol, R.G., 161 Katon, W., 162–6, 169, 174–7 Katsakou, C., 75 Keller, M.B., 169 Kellogg Foundation, 36 Kelly, C.M., 123 Kendler, K.S., 116, 123 Kendrick, T., 167 Kenny, D.A., 48, 50–1, 199, 204 Kenny, J.E., 155 Keon Report, 155 Kessler, D., 163 Kessler, R.C., 3, 80, 211, 221 key components profile, 52 Kidd, S., 137 Kidd, S.A., 206 Killackey, E., 216, 218, 227 Killaspy, H., 191 King, R., 189, 192, 206 Kirby Report, 136, 155 Kirsh, B., 187 Kisely, S., 70, 77, 163 Kjellin, L., 117 Knapp, M., 185, 187 Kneebone, P., 83

Index

Knight, M.T.D., 121, 127 Knoedler, W.H., 184, 190, 203 Koegel, P., 151 Koepsell, T.D., 36, 41, 53 Kolbasovsky, A., 65 Koletsi, M., 219 Kolodziej, M.E., 120 Koziol-McLain, J., 57–8 Krahn, D.D., 173 Krakowski, M., 97 Kroner, D.G., 106 Kropp, R.P., 107 Kurzban, R., 118, 126 labelling theory. See stigma Laberge, D., 83 Lachance, K., 184 Lafave, H.G., 185 Lafayette, J.M., 98 Lakeman, R., 180 Lamb, H.R., 83–4, 91 Lambert, E.W., 49 Lamberti, J.S., 92, 194 Lammers, J., 137 Latimer, E., 46, 185, 188, 202, 214, 216–17 Lauber, C., 120 Law, A., 120 Laws, G., 156 Lawton-Smith, S., 69 Leaf, P.J., 80 Leary, M.R., 117–18, 126–7 Lebart, L., 109 Lebel, M-J., 66 Leckie, S., 146 Lecomte, T., 220 Lee, S., 116 Leff, J., 116, 207 Lehman, A.F., 5, 182, 184–5, 188, 216

357

Leibold, J.M., 127 Leslie, D., 228 Lester, H., 167 Levene, K.S., 107 Levenson, A., 27 Lewis, C., 65 Lewis, G., 99 Lewis, S.W., 116 Liberman, R.P., 226 Lin, E.H., 163, 166 Lindqvist, P., 96 Linhorst, D.M., 143 Link, B.G., 94, 115–17, 119, 121– 2, 127, 155–6 Lipsey, M.W., 34–7, 39, 41, 47–8, 52–3 Liu, C.F., 162, 168 Livingston, J.A., 100 Livingston, J.D., 102 Lloyd, C., 220 Local Health Integration Network (LHIN), 202 Locke, J., 5 Lockwood, A., 186, 188 London Health Sciences Centre, 158 Lord , J., 46, 129, 130, 133–4 Lovell, K., 167 Lu, M., 51 Lucca, A.M., 217 lunatic asylum, 17 Lundin, R.K., 121 Lurie, S., 187, 195 Lurigio, A.J., 85–6, 92, 194 Lyons, M., 155 Lysaker, P.H., 116 MacArthur Community Violence Study, 97 MacArthur Risk Assessment Study, 86–7

358

MacDonald, E.M., 127 Macias, C., 202 Macmillan Commission, 22 Maden, A., 103 Magnusson, D., 196 Malla, A.K., 116, 120, 124 Mandiberg, J., 212–13 Mann, R.E., 196 Mares, A.S., 217, 223 Mark, M.M., 34 Markowitz, F.E., 81, 85, 155 Marks, I.M., 185 Marrone, J., 217 Marshall, M., 186, 188 Martin, F.M., 30–1 Martin, G., 194 Marwaha, S., 116 Marx, A.J., 39, 70, 182, 185 Massey, O.T., 151 Mathers, A.T., 25 Mathers, C.D., 3 Matschinger, H., 117, 120, 123–4 Maudsley, Henry, 14 Maudsley Hospital, 16, 22 Mayne, J., 36, 38 Mazeh, D., 58 McCann, L., 112 McConnell, W., 127 McCoy, M.L., 194 McCusker, P.J., 105 McDaniel, Susan H., 160 McDavid, J.C., 38 McDermott, B.E., 104 McDonough, S., 64 McEwan, B.S., 116 McFarlane, W.R., 202, 217, 222 McGrew, J.H., 39, 184–5, 200–1, 203–4, 223, 225 McGurk, S.R., 221, 227 McHugo, G.J., 157, 200, 216, 221–3

Index

McLellan, A.T., 168, 86 McLellan, D.D., 127 McLeod, A.I., 45 McNiel, D.E., 58, 65, 84–6, 106 McPherson, K., 41, 43 McPherson, L.M., 109 McQuilken, M., 211 Meadows, G.N., 163, 166, 176 Mechanic, D., 39, 52, 81, 184–5, 196 Medication Compliance Score, 197 Mehta, S., 120 Meisler, N., 194 Melton, G.B., 101 Mendota State Hospital, 182 Mental After-Care Association, 16 Mental Health Commission of Canada, 136, 211 mental health services and violence, 97–9 mental health treatment court, 39 Mental Health Triage Scale, 60 mental hygiene, 21–8 mental illness and violence, 95–7 mental illness: burden of the disease, 3; costs, 3; lifetime risk, 3; percentage treated, 3; prevalence, 3; terminology, 14–15 Mental Patients Association (MPA), 131 Mental Retardation Facilities and Community Mental Health Centers Construction Act, 30 Mertens, D.M., 45 methods-driven approach, 36, 52 Michael, B., 37 Mill, J.S., 8 Miller, D.T., 125 Miller, F.E., 117 Miller, M., 115 Mills, J.F., 106 Milton, J., 97

Index

Minghella, E., 184, 186 Ministry of Employment and Social Solidarity (Québec), 230 Ministry of Health and Social Services (Québec), 230 Mino, Y., 119–20 Minsky, S., 151 Mitchell, T., 142 mixed method, 34 mobile crisis units, 66 models: attribution, 37; autoregressive integrated moving-average (ARIMA), 45; causal, 37–9, 52; link, 37; pre-post, 38; program logic, 37–40; statistical, 44 Moffitt, T.E., 88 Monahan, J., 80, 87–8, 96–7, 99, 103–5, 109 Moore, M.E., 92 moral treatment, 18–21 Moran, J.E., 21 Moran, P., 85, 87–8 More for the Mind (Tyhurst Committee Report), 31 Morin, D., 83 Morrison, J.K., 119 Morrissey, J.P., 81, 92, 194–5 Morse, G.A., 39, 185 Moser, L.L., 205 Mossman, D., 103 Motiuk, L.L., 96 Mowbray, C.T., 138, 200 Mowrer, O.H., 131 Moxley, D.P., 138 Mueser, K.T., 87–8, 96, 98–9, 111– 12, 186, 216, 219, 221–2, 226–7 Muijen, M., 185 Mulder, C.L., 59 Mullen, E.J., 104 Mullen, P.E., 81, 86 Mulvale, G., 162

359

Mulvey, E.P., 85–7, 103, 106, 110 Munetz, M.R., 74 Murray, S.L., 127 Myin-Germeys, I., 123 National Community Awareness Campaign, 119 National Comorbidity Study, 86 NCR (not criminally responsible on account of mental disorder), 99–101 Neale, S., 187 Nelson, G., 46, 48, 133–4, 140–4, 148, 151–2, 156–7, 202 Neumeyer-Gromen, A., 162, 165 neurology, 23 New Hampshire dual-disorder assertive community treatment study, 98 Newberry, J., 137 Newman, L., 42 Newton, R., 193, 200 Ng, P., 119–20 NGRI (not-guilty-by-reason-ofinsanity), 81 Nicholls, T.L., 106–7, 110 Niles, E., 140 Noble, P., 97 Nordt, C., 120 Norko, M.A., 102 Norman, R.M., 115–17, 120, 123–7 Novac, J., 147 Noyes, A.P., 27 Nuechterlein, K.H., 227 Nygard, S., 71 O’Brien, K.P., 45, 68–9, 74 O’Connell, M., 209 O’Donnell, M., 139 O’Keefe, C., 71

360

Index

Ochocka, J., 133, 141, 143 Ogloff, J.R.P., 106 Ohayon, M.M., 100 Øhlenschlaeger, J., 205 Oldman, J., 217–18 On Our Own, 131 Onken, S.J., 5 Ontario Council of Alternative Businesses, 141 Ontario Criminal Court Review Board, 195 Ontario Disability Support Program, 154, 158 Ontario Ministry of Health and Long Term Care, 182, 184, 186– 7, 195, 201–2, 206 Ontario Ministry of Health framework paper on mental health (1999), 56 Ontario Ministry of Health Technical Advisory Committee, 201 Ontario Peer Development Initiative, 141 Ontario Works, 154, 158 Open the Doors, 119 Ormel, J., 3 Orwin, R.G., 39 Osborne-Way, L., 129 Ostman, M., 117 Ottawa Charter for Health Promotion, 146 Page, S., 94 Palmer-Erbs, V., 142 Pandiani, J.A., 86–7 Pape, B., 130, 135 Paquet, J., 100 Paquette-Warren, J., 52, 162 Paradis, A.M., 19 Paradis, M., 56

Park, B., 124 Parker, G.F., 194 Parkinson, S., 149–50 participatory action research, 142. See also consumer participation Pasewark, R.A., 97 Patrick, D.L., 47 Patterson, J., 147 Patton, M.Q., 34 Paykel, E.S., 119, 124 Peck, E., 143 Pederson, L., 36–7, 45, 52 Penn, D.L., 118–19, 124 Perlin, M.L., 99 Persons, J.B., 41, 42, 53 Pescosolido, B.A., 115, 123 Petchers, 119 Petrila, J., 69, 99 Pettigrew, T.F., 120 Petursson, H., 96 Peveler, R., 167 Pham, T.H., 109 Phelan, J.C., 94, 115–16, 120, 122–3 Phillips, S.D., 186, 204 Piat, M., 156 Pinel, P., 19–20; humane methodology of, 20 Pinfold, V., 119–20, 122 Pistrang, N., 140 Pogorzelski, W., 40, 43, 47 Pogrebin, M.R., 98 Polak, P., 116 Poole, D., 98 Porporino, F.J., 96 Porter, B., 146 Posavac, E.J., 36–8, 43, 44–5, 52 power, statistical (for causal estimates), 45 Poythress, N.G., 85, 87–8

Index

Pratt, J.G., 147 Pratto, F., 126 Prescott, L., 143 Preston, N.J., 71, 74 Preventing No Fixed Address after Discharge program, 158 Priebe, S., 75, 102, 205, 211 Priest, H.M., 180 Prilleltensky, I., 133–4 Primary Health Care Transition Fund, 180 Prince, N., 203 Prior, L., 55 PRISM psychosis study, 188–9 program evaluation and anti-stigma campaigns. See stigma prosumers, 138 Provencher, H.L., 211 Pruett, S., 83 PSE (Present State Examination) Insight Score, 197 Psychiatric Acute Care and Emergency Team (PACE), 189. See also Assertive Community Treatment Psychiatric Assertive Continuing Care Team (PACT), 189. See also Assertive Community Treatment Psychopathy Checklist-Revised (PCL-r), 107 Putting People First, 136 Quaker, 17 qualitative method, 34, 46, 51; case study, 46; focus group, 46; participatory action research, 46, 51 Quanbeck, C.D., 86 quantitative method, 34–5, 41, 46, 51 Quinsey, V.L., 104–5, 110–11

361

Rachlin, S., 81–2 Raiff, N.R., 130 Ralph, R.O., 133 randomized controlled trial (RCT), 36, 41–3, 52 Rapp , C.A., 47, 225 Raudenbush, W., 48, 50 Razzano, L.A., 221 REACT study, 190 Read, J., 120 Reark Research, 119 Reaume, G., 130 recovery, 121 Recovery, Inc., 130 Recovery Self Assessment Questionnaire, 206 Reda, S., 120 Redko, C., 203 Reeve, P., 143 Reeves, S., 180 Regalado, Sophie M., 178n Regier, D.A., 95, 163, 180 Regional Mental Health Care – London, 158 regression, 44; to the mean, 49 reliability(of data), 35, 46 Remington, T.L., 180 Resnick, S.G., 209 Reville, D., 135 Reynolds, A.J., 36 Reynolds, I., 187 Rice, M., 87, 102, 111 Richards, D.A., 45, 167 Richeson, J.A., 125 Ridgely, M.S., 98 Rimer, B.K., 36 Rinaldi, M., 217–18, 227 Ring, K., 115 risk assessment. See violence and risk assessment and management

362

Index

Risk for Sexual Violence Protocol (RSVP), 107 risk management. See violence risk assessment and management Rissmiller, D.J., and J.H. Rissmiller, 131 River, L.P., 116, 118 Robertson, R.G., 100 Robins, J.M., 49 Robins, L.N., 87, 95 Rochefort, D.A., 161 Roe, D., 5, 116 Roesch, R., 100 Rogers, E.S., 142, 151, 215 Rogers, P.J., 38 Rohan, M.J., 126 Rohland, B.M., 74 Rokeach, M., 126–7 Rollins, A.L., 214 Rolls, L., 180 Romans, S., 76 Romeo, R., 46 Rorem, R.C., 27–8 Rosen, A., 119, 122, 184, 186, 190, 205 Rosenfield, S., 116 Rosenheck, R.A., 85, 112, 116, 185, 187, 211, 217, 223, 228 Ross, F., 180 Ross, K., 140 Rossi, P.H., 36–7, 43–4 Rost, K., 167 Rothman, D.J., 27 Rothman, K.J., 49 Rowe, M., 140 Rowland, N., 168, 170, 174 Royal Commission on Mental Illness (GB), 1957, 31 Roy-Bujnowski, K.M., 89–91 Rusch, N., 123

Russell, G., 151, 157 Rybczynski, W., 147 Sabin, J.E., 143 Salkever, D.S., 45, 51, 211 Salyers, M.P., 198, 200, 206, 211, 219, 222–3 Samet, J.H., 168 sample size determination, 45–6 Sands, N., 64, 67 Santos, A.B., 184–5, 216 Sarkella J., 33 Sartorius, N., 122, 163 Scheid-Cook, T.L., 71, 74 Schildcrout, J.S., 49 Schizophrenics Anonymous, 130 Schneider, J., 211 Schneider, R.D., 100 Schoenbaum, M., 172 Schultz, P.W., 125 Schulze, B., 88, 94, 97, 117, 119, 120, 155–6 Schulze, H., 122 Schutt, R.K., 151 Schwartz, S.H., 126 Scott, H., 86 Scott, J.E., 39, 185 Scull, A.T., 19, 25 Sealy, P., 32 Seasons, M., 156 Sechrest, L., 37–8 Sechrist, G.B., 125 SEEI (System Enhancement Evaluation Initiative) Coordinating Centre, 53 Segal, S.P., 71, 73–4, 80, 85, 90, 140–1 Seiter, R.P., 96 self-help movement. See consumer participation

Index

self-stigmatization. See stigma Sellick, K., 120 Senate Standing Committee on Social Affairs, Science and Technology, 136 sensitivity, 35, 46 Sensky, T., 71, 74 Shadish, W.R., 43–4, 51 Shapiro, S., 80 shared care. See collaborative mental health care Shear, M.K., 36, 41, 42 Sheldon, C.T., 85 Sher, I., 117 Shera, W., 119–20 Sherbourne, C.D., 170, 172, 175 Sherman, J.W., 127 Shields, L., 180 Short Term Assessment of Risk and Treatability (START), 106 Sidani, S., 36, 37–8 Silberschatz, G., 41–2, 53 Silver, E., 83–5, 88–9, 92, 111 Silverman, C., 140–1 Simmonds, S., 55 Simmons, H.G., 26, 31–2 Simon, G.E., 163 Simonds, L.M., 123 Simpson, E.L., 48, 143 Singer, J.D., 49 Sirey, J.A., 155 Skeem, J.L., 83, 85, 87, 103–4, 106, 110 Slade, M., 188–9 Smart, D., 60, 64 Smith, G.C., 179 Smith, L., 193, 200 Smith, M.L., 34 Smith, S.M., 162, 164, 169, 172, 176–7

363

Snijders, T., 48, 50 Snow Jones, A., 51 Socall, D.W., 117 social determinants of health, 179 social distancing preferences. See stigma social enterprises, 212 Solomon, P., 138–9, 194, 205, 211 Sorrentino, R.M., 115 Soyka, M., 86 Speer, D.C., 40–3, 47–9 Spicer, G., 188 Spousal Assault Risk Assessment (SARA), 107 Spurr, P., 49 Spurrell, M., 65 stakeholders, 48 Stame, N., 35–6, 52 Stangor, C., 125 statistical methods: analysis of covariance, 49; analysis of variance (ANOVA), 49; general linear models, 50; generalized estimatingequation (GEE), 49; growth curve modelling, 50; hierarchical linear modelling, 49; interrupted time series (ITS), 43–5 (short time series, 44; ABAB, 44); MannWhitney test, 49; mixed-level, multi-level modelling, 43–4, 49, 50, 53; multiple regression, 51; propensity score analysis, 51; random-effects regression, 49; regression discontinuity designs (RDD), 43, 44; time-dependent Cox-modelling, 49; Wilcoxon Signed Rank test Steadman, H., 72, 74, 81, 83, 86, 95, 99, 109, 155

364

Index

Stein, L.I., 182–5, 202, 216 Stein, M., 23 stepped treatment, 163 stepwise approach, 52 stereotyping. See stigma Stevenson, G.S., 27–8 stigma, 155–6; and attitudes, 119, 120, 124–7; and behavioural intentions, 119; and campaigns against, 119; and cognitive behavioural interventions, 121; and controlled group studies, 119; and coping techniques, 121, 123; and effect of the knowledge of biological causation of mental illness, 120, 123; and effects of contact with persons with mental illness, 120, 124; and efforts to reduce, 118–22, 125–7; and employment, 116; and evaluation of programs about, 118–27; and families of persons with mental illness, 117; and housing, 155–6; and labelling theory, 115; and particular diagnoses, 115; and public attitudes, 123; and research designs to understand, 119; and self-protective reactions, 117–18; and self-stigmatization, 116–17; and social distancing preferences, 117, 119, 124; and social support, 116; and stereotypical beliefs, 117; Stone, A.A., 75 Stowell, K.R., 209 Strain, J.J., 179 Strathdee, G., 189 Structured Assessment of Violence Risk in Youth (SAVRY), 107

Stuart, E.A., 181 Stuart, G.W., 186 Stuart, H., 88, 95 Stürmer, T., 51 Styron, T.H., 39 Sullivan, A.M., 102 Sullivan, G., 148 Summers, M., 64 supported employment: Individual Placement and Support (IPS), models of, 212–31; choose-getkeep model of, 215; client preferences and outcomes for, 221; cognitive remediation for IPS involvement, 227; effectiveness of vocational advisors in, 225; enterprises adaptées and, 213; high-fidelity implementation of, 224–5; improved management of illness and co-morbidities, 228; improving effectiveness of programs of, 224–8; Individual Placement and Support (IPS) models of, 212–13; individualized and long-term support of clients and, 223; integration of vocational advisors into clinical team and, 222; model description of, 215–16; non-vocational outcomes and, 214, 218–20; optimizing implementation of current model of, 224–6; “place-train” and “train-place” paradigms of, 212; potential model enhancements of, 226–8; program incentives and, 225; provision of benefit counselling and, 223–4; rapid job search and, 221–2; recovery and, 214;

Index

responsibility for, 230; rules concerning benefits and, 225–6; sheltered employment and, 213; support for individual IPS principles, 220–4; supported education and career development for IPS, 227–8; technical assistance centres for, 230; vocational outcomes and, 216–18; workplace skills training for IPS, 226–7; zero exclusion and, 220–1 Sussman, S., 26 SWAN study, 217 Swanson, J.W., 70, 72, 74, 77, 85–6, 88–9, 95, 99 Swanson, S., 225 Swartz, J.A., 92 Swartz, M.S., 70, 72–4, 76–7, 85–6, Swindle, R.W., 167 Sytema, S., 189, 191 Szasz, T., 29 Szmuckler, G., 73 Tansella, M., 56, 69 Tanzman, B., 151 Tauber, R., 226 Taylor, J., 90 Teachman, B.A., 127 Teague, G.B., 184, 190, 206 Team for Assessment of Psychiatric Services, UK, 207 Teesson, M., 186 Telson, H., 72 Tengström, A., 85, 88, 99, 106 Teplin, L., 80–8, 94, 96, 116 Terry, D.J., 125 Test, M.A., 39, 98, 182–5 theoretical framework, 36, 52

365

theory, 35, 40, 51; of cause and effect 36–9, 52; of implementation 36–7, 52 therapeutic community movement, 31 Theriot, M.T., 80, 85, 90 Thompson, K.S., 184–5 Thornicroft, G., 55–6, 69, 188–9 Thorpe, S.J., 123 Tibbo, P., 185 Tiihonen, J., 95–6 Tones K., 41, 53 Toro, P.A., 151 Torrey, J., 69–70, 82, 111–12 Toulmin, H., 119–20 Tracy, B., 131 Trafimow, D., 125 Training in Community Living, 181 Trainor, J., 132, 134–5 Transition into Primary-Care Psychiatry (TIPP), 166 Trieman, N., 207 Trinh, N-H. 207 Tropp, L.R., 120 Trotter, S., 30 Tsang, H.W., 216, 227 Tsemberis, S., 198, 206 Tuke, D.J., 21 Tuke, W., 14, 17 Twamley, E.W., 216–18 Tyhurst Committee, 31: report More for the Mind, 31 UK 700 research study, 190–2 unbiased estimate, 44 Underhill, C., 155 Universal Declaration of Human Rights, 146 Unutzer, J., 162, 168, 177

366

Index

Upfold, J., 60 Ursuline Nunnery, Trois Rivières, 20 Valentine, M.B., 143 validity, 34–6, 46; content, 47; construct, 47; external, 42, 49; internal, 44–5, 49 van Os, J., 123 Van Putten, R.A., 71, 74 van’t Veer, J.T., 117 van Velhduizen, J.R., 210 Viding, E., 90 Vingilis, E., 33, 36–7, 40, 43, 45–8, 50–2, 60, 64, 162, 186, 196, 207 violence and mental illness, 95–7 Violence Risk Appraisal Guide (VRAG), 105 violence risk assessment and management: and categories of risk factors, 103–5; and Canadian legal concept of NCR (not criminally responsible on account of mental disorder), 99–100; and changes in Canadian criminal code provisions, 99–102; and changes in civil legislation, 99; complications from substance abuse and alcohol misuse, 98–9; and epistemological considerations, 110–11; and ethical considerations, 111; following de-institutionalization, 98; implementation issues regarding, 111–13; in mental health services, 97; non-forensic settings, 97–9, 101–2; and methodological considerations, 108–10; and structured professional judgment vs actuarial approaches to, 104–13

vocational rehabilitation programs, 212–13 Volavka, J., 97 Von Korff, M., 163–4 Vos, T., 3 W.K. Kellogg Foundation, 36 Waghorn, G., 220 Wahba, S., 51 Wahl, O., 88, 116–17, 121, 155 Wales, H.W., 80 Walker, I., 120 Walker, R., 156 Wallace, C., 85, 94, 96, 99 Wallace, C.J., 226 Wallach, M.A., 98, 147, 151, 155 Walsh-Bowers, R., 157 Wand, T., 64 Wandersman, A., 41, 53 Wang, E.W., 104 Ward-Griffin, C., 148–9, 156 Warner, J.P., 162, 167 Warner, R., 116, 122, 212–13 Watson, A.C., 80, 83, 95, 115–17, 119, 127 Watts, J., 205 Watzlawick, P., 132 Way, B.B., 59 Webb, S.A., 180 Webster, C., 103–10 Weinberger, L.E., 84, 91 Weiner, D.B., 19 Weisbrod, B.A., 188 Weisman, R.L., 194 Weisner, C., 168 Weiss, C.J., 36–7, 44 Weitz, D., 130–1 Weller, B.G.A., 99 Weller, L., 120 Weller, M.P.I., 99

Index

Wells, K.B., 170–1, 175 Wessely, S., 96 Wexler, B.E., 227 White, C.L., 69 Whitehead, P., 32 Whitty, P., 174 Wilk, Piotr, 181 Willett, J.B., 49 Williams, D.H., 98 Williams, D.R., 116 Williamson, S., 109 Williamson, T., 207 Wills, T.A., 116 Wilson, D., 39 Winko v. British Columbia (Forensic Psychiatric Institute), 102 Witheridge, T.F., 194, 206 Wittchen, H.U., 3 Wolff, N., 40, 43, 47, 80, 88–9 Wong, K., 216 Working Alliance Inventory, 197 Working Like Crazy, 141 Workman, J., 21, 24 Workplace Fundamentals, 226 Workplace Risk Assessment-20 (WRA-20), 107

367

World Health Organization, 146 World Psychiatric Association, 119, 122 Wormith, J.S., 82 Wright, D., 16 Wu, L., 151 Wykes, T., 188–9 Wynaden, D., 46, 56, 64 Xie, H., 221 Yampolskaya, S., 39, 52 Yang, L.H., 126 Yau, L.H.Y., 181 Yolles, S., 29 York Asylum, 18 York Retreat, 17 Younes, N., 163 Yu, Y., 116 Zanni, G., 71 Zapf, P.A., 100 Ziegenbein, M., 59 Ziguras, S.J., 186 Ziviani, J., 155 Zubritsky, C., 137 Zwarenstein, M., 180