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Book Forum: Public Health Perspectives   |    
Community Mental Health Teams: A Guide to Current Practices
HARRIET P. LEFLEY, Ph.D.
Am J Psychiatry 2005;162:1989-1990. doi:10.1176/appi.ajp.162.10.1989
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Miami, Fla.

By Tom Burns. New York, Oxford University Press, 2004, 211 pp., $49.95 (paper).

Community mental health teams are a vital component of community support systems for people with serious mental illness, particularly for people with a history of institutional care. This book is about community mental health teams in the United Kingdom, but the authors describe them as fairly universal and generic in form. They are multidisciplinary teams in which professionals typically cross disciplinary lines to assume multiple roles of case management. The teams offer home outreach, on-site medication monitoring, aid with multiple living tasks, psychosocial rehabilitation, and, often, supportive therapy. Regardless of composition, their goals are to reduce relapse and to facilitate community integration and an improved quality of life for the people they serve.

Closest to the British model in the United States are the Program for Assertive Community Treatment teams. These teams represent evidence-based practice for serious mental illness, supported by many years of rigorous research as major deterrents to rehospitalization and channels to improved functioning in the community. Multidisciplinary Program for Assertive Community Treatment teams ideally represent psychiatry, psychiatric nursing, psychology, and social work as well as occupational therapy and rehabilitation counseling. They include vocational and substance abuse specialists and, often, consumers. The psychiatrist provides a minimum of 16 hours of time for every 50 clients. Teams are presumed to have a staff-to-client ratio of no more than 10 clients per staff member (1). The Program for Assertive Community Treatment model has its detractors but is strongly supported by the National Alliance for the Mentally Ill, which for years distributed this program’s manuals and materials to service providers under a grant from the Center for Mental Health Services. According to the latest available data from the National Association of State Mental Health Program Directors, 38 states currently fund Assertive Community Treatment programs.

Burns’s book goes far beyond the manual stage, beginning with the historical background of community psychiatry in relation to the emergence of community mental health teams. Descriptions of their organization and structure are enriched by a discussion of team dynamics and modes of dealing with professional and personality differences, role blurring, and other problems of multidisciplinary teams. Issues of ethnic diversity, balancing therapy and bureaucracy, contingency planning and risk assessment, governance, and audits of care pathways are addressed, with helpful forms included. Generic adult community mental health teams are compared with specialized assertive outreach teams in the United Kingdom and with Program for Assertive Community Treatment models in the United States. There is a section on early intervention teams that deal with people in their first episode of psychosis and, sometimes, with early detection. Included are high-risk and prodromal teams, subdivided into early intervention, prodromal intervention, and continuing care teams with specific criteria for "ultra high-risk subjects" and modes of intervention. There is a brief but good discussion of family psychoeducation, support groups, and behavior management. Crisis resolution and home treatment teams are very welcome additions that fill a yawning gap in the service system—provision of on-site treatment during a psychotic episode for people who reject clinical services and who, in fact, may be completely outside of the system.

Overall, this is a comprehensive and well-researched book for community psychiatrists concerned with serious mental illness as well as a practical tool for team builders. The book has a helpful discussion of issues, offers a wide variety of models that take into account diagnostic diversity and illness trajectory, and contains valuable materials for assessment and management of both cases and teams. There are some deficit areas. The discussion of burnout is quite cursory. One of the big problems with community mental health teams, perhaps even more than other services, is the retention of staff. These are demanding services with relatively low pay and often a 24-hour time commitment. This makes for high turnover, which is detrimental to both staff and patients. Psychiatrists in particular may tend to view these as stopgap or temporary positions rather than as ongoing roles in service delivery. Professional roles in community mental health teams require energy, dedication, and, above all, a conviction that one’s efforts will lead to more fulfilling and satisfying lives for individuals with serious mental illness. It is a career goal well worth the investment, and this book is well worth an investment of time and, one hopes, implementation.

Allness DJ, Knoedler WH: A Manual for ACT Start-Up: Based on the PACT Model of Community-Based Treatment for Persons With Severe and Persistent Mental Illness. Arlington, Va, National Alliance for the Mentally Ill, 2003
 
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References

Allness DJ, Knoedler WH: A Manual for ACT Start-Up: Based on the PACT Model of Community-Based Treatment for Persons With Severe and Persistent Mental Illness. Arlington, Va, National Alliance for the Mentally Ill, 2003
 
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