Am J Psychiatry 1995; 152:1111-1123
Copyright © 1995 by American Psychiatric Association
Research on field-based services: models for reform in the delivery of mental health care to populations with complex clinical problems
AB Santos, SW Henggeler, BJ Burns, GW Arana and N Meisler
Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston 29425, USA.
OBJECTIVE: Clinical services for psychiatrically impaired populations have
only recently been studied with scientifically valid designs to explore
innovations in structure, accessibility, and financing. Health systems
reform in the United States has provided the impetus for better defining
clinically effective and cost-sensitive models for mental health services.
This article reviews assertive community treatment, used for adults with
severe mental illnesses, and multisystemic therapy, used for adolescents
with serious emotional disturbances, as examples of service system
innovations that have been studied with controlled clinical trial designs
and have demonstrated efficacy in treating difficult and costly clinical
populations. METHOD: The authors reviewed the published controlled clinical
trials of assertive community treatment and multisystemic therapy, focusing
on the clinical and administrative elements that distinguish them from
traditional service systems. RESULTS: A qualitative assessment of these two
approaches suggests that they share common elements, with important
implications for mental health policy. Specifically, the use of an
ecological model of behavior applied to mental health patients is critical
to both systems. In addition, therapeutic principles emphasizing pragmatic
(outcome-oriented) treatment approaches, home- based interventions, and
individualized goals are key elements of their success. Most important,
both systems embody a therapeutic philosophy demanding therapist
accountability, in which personnel are rewarded for clinical outcomes and
therapeutic innovation rather than for following a prescribed plan.
CONCLUSIONS: As empirically tested approaches, assertive community
treatment and multisystemic therapy provide a scientific foundation for
continued reform and serve to illustrate critical elements in designing new
community treatment initiatives for behavioral as well as medical
conditions.
