Selby C. Jacobs, MD


Jeanne L. Steiner, DO


Samuel A. Ball, PhD


Larry Davidson, PhD


Joanne DeSanto Iennaco, PhD, APRN


Esperanza Díaz, MD


Thomas J. McMahon, PhD






Robert M. Rohrbaugh, MD


Michael J. Sernyak, MD


Thomas H. Styron, PhD


Howard Zonana, MD



Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide.Oxford is a registered trade mark of Oxford University Press in the UK and certain other countries.

Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America.

© Oxford University Press 2016

First Edition published in 2016

All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license, or under terms agreed with the appropriate reproduction rights organization. Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above.

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Library of Congress Cataloging-in-Publication Data
Yale textbook of public psychiatry/edited by Selby C. Jacobs and Jeanne L. Steiner.
p. ; cm.
Textbook of public psychiatry
Includes bibliographical references and index.
ISBN 978–0–19–021467–8 (alk. paper)
I. Jacobs, Selby, 1939–, editor. II. Steiner, Jeanne L., editor. III. Title: Textbook of public psychiatry. [DNLM: 1. Community Mental Health Services—United States. 2. Community Psychiatry—United States. WM 30.6] RC443

987654321 Printed by Sheridan, USA

is material is not intended to be, and should not be considered, a substitute for medical or other professional advice. Treatment for the conditions described in this material is highly dependent on the individual circumstances. And, while this material is designed to o er accurate information with respect to the subject matter covered and to be current as of the time it was written, research and knowledge about medical and health issues is constantly evolving and dose schedules for medications are being revised continually, with new side e ects recognized and accounted for regularly. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulation. e publisher and the authors make no representations or warranties to readers, express or implied, as to the accuracy or completeness of this material. Without limiting the foregoing, the publisher and the authors make no representations or warranties as to the accuracy or e cacy of the drug dosages mentioned in the material. e authors and the publisher do not accept, and expressly disclaim, any responsibility for any liability, loss or risk that may be claimed or incurred as a consequence of the use and/or application of any of the contents of this material.

To people recovering om serious mental illnesses and substance use disorders and to those who serve them through clinical services, education, and research.

Foreword ix Preface xi Acknowledgments xiii Contributors xv

1. Introduction and Signi cance 1 Selby C. Jacobs, Samuel A. Ball, Larry Davidson,
Esperanza Díaz, Joanne DeSanto Iennaco,
omas J. McMahon, Robert M. Rohrbaugh,

Jeanne L. Steiner, omas H. Styron, Michael J. Sernyak, and Howard Zonana

2. e Service System of Public Psychiatry 15 Selby C. Jacobs, Andres Barkil-Oteo, Paul DiLeo,
Patricia Rehmer, and Larry Davidson

3. Recovery and Recovery-Oriented Practice 33 Larry Davidson, Janis Tondora, Maria J. O’Connell,
Chyrell Bellamy, Jean-Francois Pelletier, Paul DiLeo,
and Patricia Rehmer

4. Community Supports and Inclusion 49 omas H. Styron, Janis L. Tondora,
Rebecca A. Miller, Marcia G. Hunt,
Laurie L. Harkness, Joy S. Kaufman,

Morris D. Bell, and Allison N. Ponce

5. Integrated Health Care 63 Aniyizhai Annamalai, Cenk Tek, Michael J. Sernyak,
Robert Cole, and Jeanne L. Steiner

6. Substance Use Disorders and Systems of Care 81 Donna LaPaglia, Brian Kiluk, Lisa Fucito,
Jolomi Ikomi, Matthew Steinfeld,
and Srinivas Muvvala

7. Public Health Concepts in Public Psychiatry 97 Joanne DeSanto Iennaco, Jacob Kraemer Tebes,
and Selby C. Jacobs

8. e Interplay Between Forensic Psychiatry and
Public Psychiatry 115 Reena Kapoor, Susan Parke, Charles C. Dike,
Paul Amble, Nancy Anderson, and Howard Zonana



9. Children, Adolescents, and Young Adults
in the Publicly Funded System of Care 133 omas J. McMahon, Nakia M. Hamlett,
Christy L. Olezeski, Timothy C. Van Deusen,
Natasha Harris, and Doreen J. Flanigan

10. Early Intervention and Prevention for
Psychotic Disorders 155 Jessica M. Pollard, Cenk Tek, Scott W. Woods,
omas H. McGlashan, and Vinod H. Srihari

11. Hospital Services 171 Charles C. Dike, Marc Hillbrand, Richard Ownbey,
Daniel Papapietro, John L. Young, Srinivas Muvvala,
and Selby C. Jacobs

12. Outpatient Behavioral Care Services 185 Deborah Fisk, Joanne DeSanto Iennaco,
Donna LaPaglia, and Aniyizhai Annamalai

13. Clinical Competence in Outreach and for
Special Populations 197 Anne Klee, Lynette Adams, Neil Beesley,
Deborah Fisk, Marcia G. Hunt, Monica Kalacznik,
Howard Steinberg, and Laurie Harkness

14. Cultural Competence and Public Psychiatry 211 Esperanza Díaz, Michelle Silva,
Elena F. Garcia-Aracena, Luis Añez, Manuel Paris,
Andres Barkil-Oteo, Aniyizhai Annamalai,

Miriam Delphin-Rittmon, and Selby Jacobs

15. Global Mental Health 223 Carla Marienfeld, Andres Barkil-Oteo,
Aniyizhai Annamalai, and Hussam Jefee-Bahloul





16. Education and Workforce Development in
Public Psychiatry 235 Jeanne L. Steiner, Chyrell Bellamy, Michael A. Hoge,
Joanne DeSanto Iennaco, Anne Klee, Allison N. Ponce,
Robert M. Rohrbaugh, David A. Ross,
omas H. Styron, and Selby C. Jacobs

17. Evidence-Based Public Psychiatry 249 Jack Tsai, Joanne DeSanto Iennaco, Julienne Giard,
and Rani A. Ho

18. Administrative Best Practices in Public Psychiatry 261 Andres Barkil-Oteo, Margaret Bailey, Robert Cole,
Miriam Delphin-Rittmon, Susan Devine,
Selby C. Jacobs, Jeanne L Steiner, Louis Trevisan,

and Michael J. Sernyak

19. Conclusion and Future Challenges 273 Selby C. Jacobs, Samuel A. Ball, Larry Davidson,

Esperanza Díaz, Joanne DeSanto Iennaco, omas J. McMahon, Robert M. Rohrbaugh, Jeanne L. Steiner, omas H. Styron, Michael J. Sernyak, and Howard Zonana

Index 287


The emergence of this important textbook on pub- lic psychiatry signals a new era of transformative work in this area from a department with a long and distinguished history in the eld. e Yale Department of Psychiatry was established by the Yale Medical School in 1930, under the leadership of Eugen Kahn, a protégé of the pioneer Emil Kraeplin. However, the Department emerged in its current form in 1948, as a result of a fundamental restructuring of its mission and organization under the leadership of Francis (“Fritz”) Redlich, who was chair of the Department for 20 years. Dr. Redlich was a pioneer in pub- lic psychiatry whose research identi ed signi cant dispari- ties in mental health treatments available to patients from upper socioeconomic groups compared with those availa- ble to poor patients in New Haven, as documented in his seminal book Social Class and Mental Illness. rough his personal example and through his leadership, Dr. Redlich demonstrated his commitment to the development of pub- lic psychiatry as an academic discipline with prominence in the Department equal to that of biological and psy- chological research. In 1957, Dr. Redlich began pioneer- ing discussions with Abraham Ribico , then Governor of Connecticut, about the creation of a public psychiatry insti- tute to address mental health disparities. A er President Kennedy signed the Community Mental Health Center Act in 1963, Dr. Redlich implemented these plans with fed- eral and state assistance. e Connecticut Mental Health Center (CMHC), opened in 1966, remains an exemplar of a public–academic partnership between the State of Connecticut Department of Mental Health and Addiction Services and Yale University. As we near the 50th anniver- sary of CMHC’s founding, Dr. Redlich’s vision of a public psychiatry institute fostering lively interdisciplinary faculty exchanges leading to improved outcomes for patients in the public sector has been fully realized. e programs at CMHC, including a clinical neuroscience unit to develop new biological treatments, have helped vulnerable and dis- advantaged populations, with a special emphasis on those from ethnic and cultural minorities. e public psychiatry research portfolio at CMHC helped establish the evidence

base for many public psychiatry clinical interventions and currently includes projects on ensuring patient’s perspec- tives are included in service development and delivery, pre- vention of mental health disorders through school-based interventions, early interventions for patients with emerg- ing psychotic symptoms, jail diversion for patients with mental illness in the justice system, and interventions for patients with addictions. A recent partnership between the CMHC and a local Federally Quali ed Health Center pro- vides an opportunity to explore integrated medical and psy- chiatric care and wellness for indigent people with serious mental illnesses and/or addictions.

Although the CMHC was founded to promote a pub- lic psychiatry mission, Yale faculty at the VA Connecticut Healthcare System (VACHS), Yale-New Haven Hospital (YNHH), and other a liated sites in the Yale Department of Psychiatry have also made substantial contributions to the eld. Over the past three decades, VA Connecticut has been a leader in pioneering and evaluating psycho- social rehabilitation programs, many of which have been disseminated widely within the national VA system. e Errera Community Care Center at VA Connecticut is widely viewed as a national model for the integration of recovery-oriented psychosocial rehabilitation into the con- tinuum of mental health care. Treatment for many patients at the YNHH, a general, not-for-pro t hospital, is reim- bursed by Medicaid and Medicare. With the expansion of Medicaid eligibility in Connecticut under the A ordable Care Act, the YNHH is increasingly serving patients pre- viously treated in public psychiatry settings. Evidence of the importance of the public psychiatry mission across all three institutions in the Yale Department of Psychiatry can be found in the contributions of 74 of our faculty members to this textbook.

Our public psychiatry faculty members provide out- standing training to students of the health professions. Medical students and psychiatric residents have opportu- nities to work on interdisciplinary teams caring for highly stigmatized, vulnerable patients, alongside nursing, psy- chology, and social work trainees. Community mental



health workers, some of whom are also consumers of men- tal health care, provide an important recovery-oriented per- spective to our trainees’ education. Our faculty members have developed toolboxes to educate others in culturally sensitive mental health care. Exposing trainees from various disciplines to a public psychiatry perspective and to compel- ling state-of-the-art clinical care and research programs has inspired generations of our trainees to become involved in public psychiatry careers. Opportunities to gain additional specialized expertise are available through highly regarded advanced fellowships in public psychiatry and in psychoso- cial rehabilitation. e deep public–academic partnerships between the Yale Department of Psychiatry and the State of Connecticut at CMHC, and our Department and the federal government at VACHS, have been and continue to be mutually bene cial to each partner. e public part- ners have provided invaluable support, and, in return, the academic partner has advocated for the mission, educated large numbers of professionals who pursue careers within the public psychiatry system, and developed national model programs that provide the evidence base to meet

contemporary challenges in public psychiatry. ese widely disseminated programs illustrate our commitment to meet the challenge of the Yale Department of Psychiatry’s mis- sion statement to diminish the disability caused by mental illness. We commend this textbook to the next generation of professionals and leaders of public psychiatry.

Robert M. Rohrbaugh, MD

Professor and Deputy Chair for Education and Career Development Residency Program Director Department of Psychiatry Director, O ce of International Medical Student Education Yale University School of Medicine

John H. Krystal, MD

Robert L. McNeil, Jr. Professor of Translational Research and Professor of Neurobiology Chair, Department of Psychiatry Yale University School of Medicine Chief of Psychiatry, Yale-New Haven Hospital


This textbook is authored and edited by faculty members of the Yale Department of Psychiatry who practice, teach, and conduct clinical and eval- uative research in public psychiatry. It is a comprehensive, integrated, and interdisciplinary introduction to public psychiatry for advanced professional students. As such, it is conceived in relation to the core, discipline-based educa- tional programs of professional students. It is guided by uni- ed educational aims, a shared teaching philosophy, and an integrated perspective (public psychiatry in relation to pri- mary care, addiction medicine, public health, and forensic psychiatry) with regard to the service system and practices of public psychiatry. It emphasizes the competencies neces- sary for professional careers in public psychiatry.

Interdisciplinary professional education is a central tenet of the educational philosophy of this textbook. is education principle stems from a conviction that inter- disciplinary team practice is the best organizational unit for providing services within a system of care to people with serious mental illnesses and substance use disorders. Essentially, the authors and editors believe that those who learn together—not only about the elements of care and the system, but also about their respective strengths, limitations, and professional aspirations—will practice better together. e net result is a stronger service unit that serves as a cornerstone of the workforce of public psychiatry. Although coming from an academic setting in a particular locality in the United States, the descrip- tion of American public psychiatry in the textbook is generally applicable to other settings. All programs in public psychiatry serve a population of individuals with serious mental illnesses and substance use disorders. In every locality, federal policies and funding sources sup- port and shape the service structures for this population. Professionals in public psychiatry, through meetings and publications, shape universal practices. Shared evidence- based practices unite practice in public psychiatry across the country. Despite variation from state to state and locality to locality, a basic foundation and knowledge base of public psychiatry prevails.

Although intended as a textbook for use in advanced, year-long internships or fellowships in public psychiatry, selected chapters can also serve as an introductory module for beginning professional students. For example, the rst four chapters include an introduction to public psychiatry by providing de nitions for terms such as serious mental ill- nesses and substance use disorders, a discussion of the serv- ice system of public psychiatry, an introduction to recovery concepts and practices, and a description of community supports and inclusion programs. Other chapters might be chosen for an introductory module given the educational aims of an introductory module.

is textbook is timely for a number of reasons. Health care reform under the A ordable Care Act considerably expands access to behavioral services for previously unin- sured people. Medicaid is a vehicle for much of the expan- sion. ose gaining coverage under Medicaid will gravitate to community health centers and behavioral health centers for care. Meeting this new demand for service requires an expanded and well-trained workforce. Already, depart- ments of psychiatry are anecdotally reporting an increase in applicants interested in public psychiatry. Many advanced fellowships in public psychiatry already exist, but more will be needed to provide essential interdisciplinary education while working with the target population within a public service system.

In a concluding chapter, this textbook suggests that aca- demic centers of public psychiatry can play an essential role in moving the eld forward. Academic divisions of public psychiatry that bring together veterans’ services and state- funded services, for example, can make rich contributions to their home departments. Some departments of psychia- try already have such divisions, and others are contemplat- ing it. In this regard, July 1 and September 28, 2016, mark, respectively, the 50th anniversary of the opening and the dedication of the Connecticut Mental Health Center in the Yale Department of Psychiatry, an illustration of an endur- ing, mutually bene cial partnership between the State of Connecticut and Yale University. In part, this textbook is a celebration of that anniversary.



As noted earlier, this textbook is intended primarily for advanced, professional students of public psychiatry. Certainly, psychiatric educators will also take an interest, not only those directly teaching public psychiatry but also other faculty members involved in departmental education, in order to appreciate how public psychiatry may t into a broader curriculum. e textbook may also be of inter- est to public administrators who wish for an overview of the eld. Finally, the textbook may be useful to people, such as individuals in recovery from serious mental illnesses and substance use disorders, and their families, who are seeking a greater understanding of treatment approaches and com- munity supports available to them.

Although the editors and authors have done their utmost to provide a comprehensive introduction to cur- rent, public psychiatry, given the anticipated transitions in public psychiatry over the next several years, it is almost inevitable that the content of the textbook will become outdated. e authors and editors anticipate this possibil- ity. Accordingly, the textbook will be updated regularly to re ect new developments. e authors and editors are pursuing academic careers in public psychiatry and will be informed of transitions that are occurring. In addition, they welcome feedback from readers of the textbook about omissions or needed updates.

e Editorial Board March 31, 2015



The Editors are grateful for support from the Psychiatry of the Yale University School of Medicine. We Connecticut Department of Mental Health thank Annette Forte and Nina Levine for their editorial and Addiction Services and the Department of assistance.



All authors are faculty members within the Yale Department of Psychiatry, who hold academic appointments at the Yale School of Medicine, Yale School of Nursing, Yale Child Study Center and/or the Yale School of Public Health

Lynette Adams, PhD

Assistant Clinical Professor Women Veterans Program Manager VA Connecticut Healthcare System

Paul Amble, MD

Assistant Clinical Professor
Chief Consulting Forensic Psychiatrist CT Department of Mental Health Service

Nancy Anderson, APRN

Director, Community Forensic Services Connecticut Mental Health Center

Luis Añez-Nava, PsyD

Associate Professor
Director, Hispanic Clinic
Connecticut Mental Health Center
Director, CT Latino Behavioral Health System

Aniyizhai Annamalai, MD

Assistant Professor
Medical Director, Wellness Center Connecticut Mental Health Center

Margaret Bailey, LCSW

Clinical Instructor
Director, Clinical Services Connecticut Mental Health Center

Samuel A. Ball, PhD

Assistant Chair for Education and Career Development President and Chief Executive O cer,
CASA Columbia

Andres Barkil-Oteo, MD, MSC

Assistant Professor
Medical Director, Acute Services Connecticut Mental Health Center

Neil Beesley, LCSW

Chief, Social Work Service
VA Connecticut Healthcare System

Morris D. Bell, PhD, ABPP

Senior Research Career Scientist
Department of Veterans A airs, Rehab R&D Program Director, NIMH Research Fellowship in Functional Disability Interventions

Chyrell D. Bellamy, PhD, MSW

Assistant Professor
Director of Peer Services and Research
Yale Program for Recovery and Community Health

Robert Cole, MHSA

Chief Operating O cer, Connecticut Mental Health Center

Larry Davidson, PhD

Director, Yale Program for Recovery and Community Health

Miriam Delphin-Rittmon, PhD

Assistant Professor
Commissioner, CT Department of Mental Health and Addiction Services


Joanne DeSanto Iennaco, PhD, APRN

Associate Professor
Specialty Coordinator, Psychiatric-Mental Health Nurse Practitioner Program
Yale School of Nursing

Susan Devine, APRN

Director, New Haven O ce of Court Evaluations Director, Risk Management
Connecticut Mental Health Center

Esperanza Díaz, MD

Associate Professor
Medical Director, Hispanic Clinic
Connecticut Mental Health Center
Medical Director, CT Latino Behavioral Health System Associate Director,
Psychiatry Residency Program

Charles C. Dike, MD, MPH, FRCPsych

Assistant Professor
Associate Program Director,
Fellowship in Forensic Psychiatry Deputy Medical Director, Department of Mental Health and Addiction Services

Paul J. DiLeo, FACHE

Chief Operating O cer,
Department of Mental Health and Addiction Services

Deborah Fisk, PhD, LCSW

Assistant Clinical Professor
Team Director, Outpatient Services Connecticut Mental Health Center

Doreen Flanigan, LCSW

Clinical Instructor
Clinician, West Haven Mental Health Clinic Connecticut Mental Health Center

Lisa Fucito, PhD

Assistant Professor
Program Director, Tobacco Treatment Smilow Cancer Hospital at Yale- New Haven

Elena F. Garcia-Aracena, MD

Clinical Instructor
Attending Psychiatrist, Hispanic Clinic Connecticut Mental Health Center

Julienne Giard, LCSW

Director, Evidence-Based Practices CT Department of Mental Health and Addiction Services

Nakia M. Hamlett, PhD

Assistant Professor
Clinician, Young Adult Service Connecticut Mental Health Center

Laurie L. Harkness, MSW, PhD

Clinical Professor
Director, Errera Community Care Center VA Connecticut Healthcare System

Natasha Harris, APRN

Clinician, West Haven Mental Health Clinic and Young Adult Service
Connecticut Mental Health Center

Marc Hillbrand, PhD

Assistant Clinical Professor
Former Chief of Psychology, Connecticut Valley Hospital

Rani A. Ho , PhD, MPH

Associate Director, Robert Wood Johnson Clinical Scholars Program
Director, Northeast Program Evaluation Center,
O ce of Mental Health Operations,
Department of Veterans A airs
Director, Evaluation Division, National Center for PTSD

Michael A. Hoge, PhD

Director, Yale Behavioral Health Director, Clinical Training in Psychology

Marcia G. Hunt, PhD

Assistant Professor
Associate Director, Veteran A airs Northeast Program Evaluation Center
O ce of Mental Health Operations, Veterans Health Administration

Jolomi Ikomi, MD

Assistant Professor
Former Medical Director, Substance Abuse Treatment Unit Connecticut Mental Health Center


Selby C. Jacobs, MD

Professor Emeritus
Attending Psychiatrist, Hispanic Clinic
Former Director, Connecticut Mental Health Center

Hussam Jefee-Bahloul, MD

Division of Substance Abuse

Monica Kalacznik, MD

Medical Director, Assertive Community Treatment Team
Connecticut Mental Health Center

Reena Kapoor, MD

Assistant Professor
Associate Program Director,
Fellowship in Forensic Psychiatry
Attending Psychiatrist, Community Forensic Team Connecticut Mental Health Center

Joy S. Kaufman, PhD

Associate Professor
Deputy Director for Operations,
Yale Consultation Center
Director, Evaluation Research,
Division of Prevention and Community Research

Brian Kiluk, PhD

Assistant Professor
Psychologist, Substance Abuse Treatment Unit Connecticut Mental Health Center

Anne Klee, PhD

Assistant Professor
Director, Peer Services and Education and Training, Errera Community Care Center
Director, Interprofessional Residency in Psychosocial Rehabilitation and Recovery Services
VA Connecticut Healthcare System

John H. Krystal, MD

Robert L. McNeil, Jr. Professor of Translational Research and Professor of Neurobiology
Chair, Department of Psychiatry
Chief of Psychiatry, Yale-New Haven Hospital

Donna LaPaglia, PsyD

Assistant Professor
Director, Substance Abuse Treatment Unit Connecticut Mental Health Center

Carla Marienfeld, MD

Assistant Professor
Site Training Director, Yale Addiction Psychiatry Fellowship
Director, Psychiatry Residency Global Mental Health Program

omas H. McGlashan, MD

Professor Emeritus & Senior Research Scientist Founder, PRIME Psychosis Prodrome Research Clinic

omas J. McMahon, PhD

Associate Professor
Director, West Haven Mental Health Clinic and Young Adult Service
Director of Clinical Research
Connecticut Mental Health Center

Rebecca A. Miller, PhD

Assistant Professor
Director, Peer Support Connecticut Mental Health Center

Srinivas Muvvala, MD, MPH

Assistant Professor
Medical Director, Substance Abuse Treatment Unit Connecticut Mental Health Center

Maria J. O’Connell, PhD

Associate Professor
Research & Evaluation Area Leader
Yale Program for Recovery and Community Health

Christy L. Olezeski, PhD

Assistant Professor
Clinician, Young Adult Service Connecticut Mental Health Center

Richard Ownbey, MD

Assistant Clinical Professor Director of Medical Education, Connecticut Valley Hospital

Daniel Papapietro, PsyD

Assistant Clinical Professor Chief of Psychotherapy Services, Connecticut Valley Hospital


Manuel Paris, PsyD

Associate Professor
Deputy Director, Hispanic Services Connecticut Mental Health System

Susan Parke, MD

Assistant Professor
Attending Psychiatrist, Community Forensic Service Connecticut Mental Health Center

Jean Francois Pelletier, PhD

Assistant Clinical Professor Psychologist, Yale Program for Recovery and Community Health

Jessica M. Pollard, PhD

Assistant Professor
Director of Clinical Services,
Program for Specialized Treatment Early in Psychosis [STEP]
Connecticut Mental Health Center

Allison N. Ponce, PhD

Associate Professor
Associate Director, Community Services Network of Greater New Haven Connecticut Mental Health Center

Patricia Rehmer, MSN

Former Commissioner, CT Department of Mental Health and Addiction Services

Robert M. Rohrbaugh, MD

Professor and Deputy Chair for Education
and Career Development
Residency Program Director, Department of Psychiatry Director, O ce of International Medical Student Education, School of Medicine

David Ross, MD, PhD

Assistant Professor
Associate Director, Psychiatry Residency Program

Michael J. Sernyak, MD

Chief Executive O cer, Connecticut
Mental Health Center
Deputy Chair, Clinical A airs and Program Development, Department of Psychiatry
Director, Division of Public Psychiatry

Michelle Silva, PsyD

Assistant Professor
Associate Director, CT Latino Behavioral Health System

Vinod H. Srihari, MD

Associate Professor
Director, Program for Specialized Treatment Early in Psychosis [STEP]
Connecticut Mental Health Center
Associate Director, Psychiatry Residency Program

Howard Steinberg, PhD

Assistant Professor
Director, Psychosocial Residential Rehabilitation Treatment Program
VA Connecticut Healthcare System

Jeanne L. Steiner, DO

Associate Professor
Medical Director, Connecticut Mental Health Center Director, Yale Fellowship in Public Psychiatry

Matthew Steinfeld, PhD

Assistant Professor
Psychologist, Substance Abuse Treatment Unit Connecticut Mental Health Center

omas H. Styron, PhD

Associate Professor
Director, Community Services Network of Greater New Haven
Connecticut Mental Health Center

Jacob Kraemer Tebes, PhD

Director, Division of Prevention and Community Research
Director, e Consultation Center
Chief Psychologist, Connecticut Mental Health Center Director, NIDA T32 Postdoctoral Research Training Program in Substance Abuse Prevention

Cenk Tek, MD

Associate Professor
Director, Psychosis Program Connecticut Mental Health Center

Janis L. Tondora, PsyD

Assistant Professor
Systems Transformation Area Leader
Yale Program for Recovery and Community Health


Louis Trevisan, MD

Associate Professor
Associate Chief, Mental Health Service Line VA Connecticut Healthcare System

Jack Tsai, PhD

Assistant Professor
Co-Director, Yale Division of Mental Health Services and Treatment Outcomes Research

Timothy C. VanDeusen, MD

Assistant Professor
Medical Director, West Haven Mental Health Clinic and Young Adult Service
Connecticut Mental Health Center

Scott W. Woods, MD

Chief, PRIME Psychosis Prodrome Research Clinic Attending Psychiatrist, Connecticut Mental
Health Center

John L. Young, MD, M

Clinical Professor

Howard Zonana, MD

Director, Law and Psychiatry Division Director, Fellowship in Forensic Psychiatry




Selby C. Jacobs, Samuel A. Ball, Larry Davidson, Esperanza Díaz, Joanne DeSanto Iennaco, omas J. McMahon, Robert M. Rohrbaugh, Jeanne L. Steiner, omas H. Styron, Michael J. Sernyak, and Howard Zonana


• Public psychiatry encompasses special clinical competencies for practice in a complex system designed to serve the needs of people with serious mental illnesses (SMIs) and/or substance use disorders (SUDs).

• Public psychiatry is particularly important at this moment in history, as public sector practice is considerably expanded under the A ordable Care Act of 2010.

• Public psychiatry is a large sector of the eld of psychiatry, one that makes an essential impact on the lives of people with SMIs and SUDs.

• e educational principles that guide this textbook derive from a commitment to an integrated system of care informed by public health.

• Important features of the service system include person-centered care, recovery orientation, interdisciplinary teams, community-based practice, cultural competence, integrated practice, population- based practice, evidence-based practice, and quality assurance, including peer and family satisfaction.
e educational principles of this textbook include the development of advanced interdisciplinary educa- tion (assuming basic clinical skills are already in place), integration of all aspects of practice, attention to a full range of services, and the cultivation of continuing self-education in a structure of supervised clinical placements, seminars, and faculty supervision.


Mental health professionals who specialize in public psy- chiatry must master a body of knowledge and domain of practice. What is public psychiatry? Who does public psy- chiatry serve? Does practice require special skills? Is there a special system of services for public psychiatry? Are there special educational needs for people interested in entering public psychiatry? What is the special content, if any, of education in public psychiatry? Is a textbook needed at this point in time? What are the educational principles of this

textbook? is introduction sets out to answer these ques- tions and thereby previews the education in public psychia- try embodied in this book.


Building on de nitions o ered by others,1,2 this textbook uses the following de nition of public psychiatry3: pub- lic psychiatry is that part of the practice of psychiatry that is (1) nanced by the general funds of state departments


of mental health or (2) by reimbursement income from entitlements such as Medicaid. For disabled, chronically ill individuals, Medicare also funds acute services, with eli- gibility determined by the Social Security Administration. In addition, the US Department of Housing and Urban Development supports residential services. Public psychia- try provides a safety net of services for low-income persons with serious mental illnesses (SMIs) and co-occurring or independent substance use disorders (SUD). e practice of public psychiatry incorporates evidence-based treatments, psychosocial rehabilitation, person-centered recovery plans of care, integration with primary care through medical homes, integration with substance use services, commu- nity supports such as housing and money management, and attention to social issues such as legal status, child protection, or homelessness. Public psychiatry is practiced in many set- tings. ese include mental health and addiction agencies, community health centers, residential and nursing care facil- ities, psychosocial rehabilitation agencies, hospital-based primary care centers, and organizations o ering forensic or public health programs. Practice typically occurs through interdisciplinary teams (IDTs). Also, given the multiplicity of settings and tasks, and also given the organizations such as community mental health centers or community health (primary care) centers where public psychiatry is practiced, system knowledge, management skills, and a community perspective are important for clinical success. Public psy- chiatry uses not only a clinical perspective while caring for the individual service user, but also a population perspective. It attends to public health data, epidemiologic studies, and health services research for the purpose of planning, evaluat- ing, implementing, and managing services.

is de nition of public psychiatry incorporates ele- ments from major historical and policy developments since 1963, when Congress enacted the Community Mental Health Centers Act during the Kennedy Administration.3 e de nition is professional, medical, clinical, and admin- istrative. It incorporates a broad clinical and public health perspective on psychiatric disorders and clinical services. Because public practice now takes place in both private and public locations, blurring the distinction between these two settings, this de nition avoids the trap of de ning public psychiatry in terms of the place or system where it is practiced.

Psychiatric services of the Veteran’s Administration (VA) Healthcare System are not included in this de nition, nor are they routinely incorporated into de nitions of pub- lic psychiatry. e VA is su ciently distinct as a national health service for veterans that it deserves separate consid- eration. e VA system deserves and, indeed, would require

an entire textbook itself. Still, public psychiatry can learn much from many parallel programs in the VA system, such as outreach programs, rehabilitation programs, and ser- vices research. Indeed, some veterans move back and forth between the systems and di er in their preferences for pub- lic versus veteran services. is textbook takes advantage of the overlap between the systems and cites VA programs and examples in subsequent chapters. In the Yale Department of Psychiatry, faculty members at the Connecticut Mental Health Center and the West Haven Campus of the VA Connecticut Healthcare System collaborate in teaching and investigations and make up a departmental academic division of public psychiatry (see Chapter 19) devoted to education and research.

e chapters following this introduction amplify a description of the service system of public psychiatry; sub- sequent chapters address clinical competence, and addi- tional chapters cover additional skills and themes that are important for successful practice in public psychiatry.


ere is no simple answer to the question of who is served by public psychiatry. e short answer is that public psychi- atry serves both children and adults who su er from SMIs and/or addictions and who sometimes make up special populations, such as people with traumatic brain injury or problematic sexual behavior, that fall to state responsibility to provide care to, if not protect society from.

e term “serious mental illness” is o en used to refer to the disorders of the core, target population served by public psychiatry. e term “serious mental illness” was coined to denote people with severe, recurrent, chronic, or persistent disabling mental illnesses and addictions.4,5 It is used interchangeably in this text with “severe and persistent mental illness,” a term that originated in stud- ies done in the Yale Department of Psychiatry.6 SMIs typically include schizophrenia spectrum disorders with residual symptoms; recurrent bipolar illness; chronic, relapsing depressive disorders; severe anxiety syndromes; and severe personality disorders, all with comorbidity and psychosocial disabilities. When substance abuse is added into the picture, which is o en the case, SMI becomes even more challenging to treat. On the substance abuse side, severe addictions can be intractable and are o en multiple, chronically relapsing, and disabling. Many of these chronic disorders are also associated with the risk of suicide and/or a risk of violence to others. As noted


earlier, public psychiatry also cares for special popula- tions, many of whom have severe and persistent illness as de ned and for whom the state takes responsibility to provide care and to protect society in circumstances of high risk. In epidemiologic studies, which estimate a 26% prevalence of all psychiatric illnesses in the American population, about 6% of the total population have the most serious illnesses (see Chapter 7). Indeed, the pop- ulation that public psychiatry serves is one of the most salient characteristics of public practice.

e root causes for psychiatric illnesses remain unknown. Although evidence-based treatments relieve symptoms, and recovery occurs in the community, cures are rarely achievable. Estimates of shortened life expectancy and years lost to disability from SMIs, known as burden of disease, place them among the top ten of all kinds of diseases (see Chapter 7). As the Mental Health Services Act of 1980 asserted, persons with SMIs served in the public sector are the most needy and vulnerable of all the people served by American psychiatry and medicine.

e pathway of a person with SMI or a SUD into public sector services varies by the nature of the illness, the course of illness over time, and access to care. Historically, examples have included young people with psychotic disorders who are no longer eligible for health insurance coverage under their parents and persons for whom the limited insurance bene ts o ered for treatment of psychiatric disorders have been exhausted. Also, many people become incapacitated and unemployed, thus making employer-based insurance inaccessible. How these various scenarios will change with current health reform e orts remains to be seen. Many people living in poverty are eligible for Medicaid and, once an illness is chronic, Medicare. ese payers can serve as a pathway into the system. Finally, many people with SMIs or SUDs are identi ed primarily, at least at rst, by a major social problem, whether it is homelessness, of which about 40% are considered seriously ill, or people transitioning out of prisons, of which about 80% are estimated to have SUDs.

In contrast to the rest of psychiatric practice, is there something distinct or di erent about those people with mental health and SUDs who are served by public psy- chiatry? Arguably, the answer is yes. e illnesses typically encountered in public practice are chronic and associated with disability. It is this combination of acute, o en recur- rent illness; chronic residual symptoms; comorbidity with various other psychiatric disorders, mental health disorders and addictions, and physical health problems; disabilities; the need for psychosocial rehabilitation and community supports; and aspirations for recovery as well as full citi- zenship that characterizes the typical person served in the

public system. Furthermore, social problems of poverty, legal embroilments, and homelessness are commonplace and intermingle inextricably with the clinical picture. is clinical complexity is a hallmark of the population served.

e target population of people served by public psy- chiatry has varied over the years since inception of the modern era in 1963. is variation has been a function of ongoing budget crises and policy initiatives that invariably lead to discussions of exactly who is the target population. (See Chapter 2 for a brief discussion of the major periods of modern public psychiatry.) At rst, during the 1970s, the de nition of the target population emphasized those who resided in a particular community (the so-called catchment in the community mental health lexicon), especially those coming out of state hospitals.

Next, as the system seemed to be failing people with chronic conditions who were discharged from hospitals into the community, the de nition of the target popula- tion swung to people with severe and persistent mental illness living in the community. During the same time in the 1980s, the target population slowly expanded as states began to use Medicaid to nance services. In these circumstances, the de nition of the target population emphasized payer status and those eligible for Medicaid. Many of these people had SMIs or SUDs; however, many others who were single and poor were excluded. Services funded by state general funds targeted the latter group, but these resources shrank as states contended with bud- get problems.

roughout the modern history of public psychiatry, populations have been identi ed as the special respon- sibility of the state, either as a last resort or to protect society. Although many special populations contained a number of people with SMIs or SUDs, the responsibil- ity of public psychiatry for its core target population was o en diluted. Despite these variations in target popula- tion de nition, the central challenge for the public system of services is still to remain true to the core population of people with severe, persistent, and disabling behavioral disorders.


Despite its apparent disorganization, there is indeed a pub- lic psychiatry service system. e current service system is a historical overlay of service and support components laid down over many years, in successive periods of development. e system for SUDs has distinct historical roots and is


o en orthogonal to mental health services, although many services for co-occurring disorders exist. e system also is strati ed at federal, state, and local levels. e US Substance Abuse and Mental Health Services Administration (SAMHSA) and state departments of behavioral health de ne the purpose and function of the system through policies, demonstration projects, and the nancing of ser- vices. County and local strati cations of management also contribute to the policies, services, supports, and nancing of the system. e mission of serving people with SMIs and/or SUDs unites these parts of the system. Evaluation, treatment, case management, early intervention, outreach to people who are homeless, psychosocial rehabilitation including work and educational supports, other commu- nity supports such as housing, integrations with primary care, forensic consultation, peer-run programs, and preven- tion of behavioral disorders make up the current system of public psychiatry. A full spectrum of mental health and addiction professionals, community-based specialists, and program managers work through IDTs within this system. Federal, state, and local sources nance the services, com- munity supports, and personnel that make up the system. On a local level, the system comprises a variety of organiza- tions: community mental health centers, federally quali ed community health (primary care) centers, general hospi- tals, emergency rooms, state-operated agencies, and private nonpro t agencies provide treatment, rehabilitation, and community supports. Each of these has particular policies, budgets, and a program of services and/or supports that they manage.

As a result of the broad array of services and supports, their disparate sources, and the historically piece-meal development of the current system (see Chapter 2), the ser- vice system of public psychiatry is complex, disjointed, and di cult to navigate. To understand it fully requires e ort studying it and time working in it. Working on the most basic level of the system, the professional in public psychia- try marshals the multiple elements of the system into indi- vidual plans of care for people with SMI and/or addiction. is process is the strongest source of cohesion currently available for making the system work e ectively for people who need care.

Chapter 2 eshes out this starting de nition of the service system of public psychiatry with a more detailed description, provides a brief history of its development as a strategy for understanding it, and ampli es a discussion of its nancing. Subsequent chapters in this textbook elabo- rate on public health, substance abuse services, primary care, recovery and social inclusion, forensic services, and other parts of the system.

is de nition of the system is universal and generic for the United States. However, below the federal level, con- siderable variation exists among state authorities for mental health and addiction services, not to mention state Medicaid programs. At the local, county, and city level, considerably more variation exists from place to place depending on state policies and local agency initiatives and development. e array of services available in each locale is a function of all of these levels. At a local level, a description of the system becomes particular and concrete. Still, the particulars of one place (such as New Haven, Connecticut, in the case of this textbook) illustrate usefully the outline of the system in many locations.

e bottom line for the service system is the array of clinical programs and community supports it provides for people with SMIs and/or SUDs, thereby enabling person- centered, individualized plans of care. A key value of this textbook is that it emphasizes that a system ought to incor- porate as full a range of services and supports as possible. In this regard, several aspects of the system, including rehabili- tative community support, public health, integrated health care, and services for co-occurring disorders and chronic addictions, deserve special emphasis because they have o en been given short shri if not ignored on the clinical side. Subsequent chapters will give full consideration to these parts of the system.


Professionals in public psychiatry must acquire expertise in caring for people with SMIs and SUDs, the central target population. Psychopharmacologic and psycho- therapeutic expertise and psychiatric consultation skills are cornerstones, but they must be supplemented by additional knowledge and skills in the areas of rehabili- tation, accommodation, navigation, and the provision of in vivo supports in various life domains a ected by these conditions.

Psychopathology for the professional in public psy- chiatry is more than knowledge of the disorders listed and de ned in the Diagnostic and Statistical Manual, Fi h Edition (DSM 5)6 In public psychiatry, the clinical picture is larger and all-encompassing. In the public sector, more so than in other domains of practice, psychiatric disorders de ned by DSM5 are associated not only with morbidity caused by relapses, but also with mortality (suicide and pre- mature death from a variety of causes) and impairment in functioning (disability or burden of disease). It is essential


for the professional in public psychiatry to attend to all these aspects of illness and their interrelationships. Accordingly, this textbook addresses the entire course of illness, all of its outcomes, and the competencies needed to be e ective in practice.

Furthermore, clinical competence in public psychiatry involves mastery of this complex clinical picture as part of an IDT of caregivers in di erent settings, not just in the hos- pital and clinic. ese include residential settings, the street, rehab centers, legal o ces, and homeless shelters. Not only must public psychiatry professionals learn to practice in all these settings, they must be savvy about the system in which they work in order to mobilize it for the people they care for. In contemporary public practice, a supported apart- ment or other residential setting, as opposed to a hospital, is o en the platform for arranging care. ese are the settings in which professionals practice without the “white coat” of the hospital setting. e key for making public services work for individuals with SMI and SUDs is the practicing professional in public psychiatry who works as part of, and o en leads, an IDT that creates personal, comprehensive, coherent, recovery-oriented, and integrated plans of care in the community while using the hospital, emergency room, and other alternatives (such as respite care) for backup in the case of acute crises.

Furthermore, it is not su cient for educators and prac- ticing professionals in public psychiatry to assure them- selves that their practice is competent. It is also necessary to measure key process and outcome indicators in the various domains of practice in order to document and then strive to improve the quality of care. Quality data, together with the cost of services, are two factors in an equation of value (with value equaling the ratio of quality over cost). Quality measures are useful not only for monitoring and improv- ing outcomes, but also for reporting transparently about the quality of services. In each domain of practice covered in this textbook, such as treatments for SUDs, ambula- tory treatment for major disorders, or assertive community treatment, the authors provide a discussion of key quality metrics in that area. A humble attitude of continually striv- ing for improvement, in contrast to assertions of profession- alism and even perfection, is the foundation for achieving quality care. Attention to quality metrics, along with inde- pendent learning, provides a building block for ongoing clinical competence in the future.

While maintaining a focus on person-centered clini- cal competence for the professional, the authors of this textbook also assume that many public psychiatry profes- sionals will advance in their careers into positions of lead- ership. e content, integration, and comprehensiveness

of the didactics in this textbook are a foundation not only for clinical competence but also for e ective leadership in the eld. e best leaders will need clinical competence; a comprehensive, integrated, interdisciplinary understanding of the eld of public psychiatry; and well-honed manage- ment skills.


Predicated on the logic developed so far, it is important to recognize that public psychiatry is an important subspe- cialty of the general mental health professions. Advanced education in public psychiatry builds on general education in the mental health professions. In general education, the professional student learns interviewing, diagnosis, psycho- therapies, psychopharmacology, consultation, and other aspects of practice in hospital, clinical, and community set- tings. Advanced education in public psychiatry builds on these foundational skills and addresses the knowledge and practice de ned earlier.

At present, public psychiatry is not o cially a subspe- cialty of psychiatry. In the past 20 years, however, several groups have made the case for such certi ed training.1,3,7 ere is a special body of knowledge to master and profes- sional organizations to support such specialists, and the development of certi ed education programs would ll an existing need, improve educational quality, and o er a bridge to the future. Within the context of current health care reform and as a result of other factors shaping practice in public psychiatry, it is all the more important to have dedicated, specialized, and certi ed professionals in public psychiatry.

ere is no doubt that public psychiatry makes impor- tant contributions to academic departments of psychiatry. In a previous volume, the authors considered the contri- butions to public psychiatry of academic programs at the Connecticut Mental Health Center of the Yale Department of Psychiatry8 (see Chapter 19 for a more detailed discus- sion of this idea). e establishment of advanced quali ca- tions in public psychiatry would enhance these academic pursuits. Also, advanced quali cations would support and consolidate a cadre of academic professionals who are needed to move the eld of public psychiatry forward in teaching and research departments of psychiatry during a time of great change. Re ecting this need, the American Association of Community Psychiatrists began certi ca- tion of advanced credentials in public psychiatry in 2015.



e editors and authors have imbued this textbook with their shared beliefs and commitments to a comprehensive curriculum in public psychiatry. Shared educational prin- ciples and philosophy guide the content, and an education structure made up of multiple interrelated parts o ers many platforms for educational experiences. is textbook con- tains the core didactics for teaching the care of people with SMIs and co-occurring or independent SUDs. In addition, the didactics are supplemented with selected, current cita- tions in the literature, re ected in the bibliographies for each chapter.

e educational principles of this textbook derive from the authors’ shared conviction in and commitment to a publicly funded system of service delivery. Optimal service delivery in the system of public psychiatry is char- acterized as a full range of services (1) provided by IDTs made up of professionals and specialists; (2) informed by an understanding, derived from public health, of the local community and its population; (3) based in the commu- nity; (4) person-centered; (5) recovery-oriented; (6) cul- turally competent; (7) integrated with primary care, addiction medicine, public health, and forensic psychiatry; (8) evidence-based; (9) competency-based (through train- ing); and (10) driven by consumer and family satisfaction as part of quality improvement. e educational principles apply to the features of the service system de ned and itemized earlier, and the organization of the textbook cor- responds largely to the typology of the system and the edu- cational principles presented earlier.

It is important to emphasize that the curriculum o ered in this textbook is predicated on the assumption that the professional student already has accomplished basic clini- cal and professional education in interviewing, evalua- tion, diagnosis, formulation, treatment, and rehabilitation. Assuring this premise is a function of screening and selec- tion of candidates for advanced education in public psy- chiatry. is principle does not exclude the possibility that selected chapters from the textbook can be used as an intro- ductory module in public psychiatry for beginning profes- sional students.

Second, this textbook is interdisciplinary in editing, authorship, content, consideration of roles, and teach- ing. It is not designed for just one professional group. e interdisciplinary character of the textbook re ects a convic- tion that practice in public psychiatry ought to be accom- plished through IDTs. Psychiatrists, psychologists, nurses, social workers, rehabilitation therapists, and peer sta bring

special skills to the task of caring for people with SMI and addictions. Working together e ectively as a team is a pro- fessional skill in itself.

Also, the textbook teaches an integrated approach to the practice of public psychiatry. e text integrates the diverse parts of a complex public system with the comple- mentary clinical, rehabilitative, and support tasks of care in the community. It integrates both public health and clini- cal perspectives. It addresses the integration of public psy- chiatry and primary care through medical homes, and it also emphasizes the challenge of integrating psychiatry and addiction medicine. e text strives for integration in order to (1) achieve a complete picture of psychiatric and SUDs in the community where they occur, (2) understand the continuum of practice from prevention and early interven- tion through treatment of acute illness and relapse preven- tion to nally easing the burden of disease while supporting recovery and citizenship, and (3) have an appreciation of how public psychiatry can help meet the challenges com- munities face, such as untreated illness, suicide, violence, addictions, and burden of disease.

Furthermore, this textbook emphasizes clinical compe- tence in the educational program. In this textbook, clinical competence is fundamentally person-centered and focused on people with SMIs and SUDs in a variety of settings. Although the human encounter is essentially the same in all of psychiatric practice, the clinical relationship varies in a population of largely poor, culturally diverse people with limited educational opportunities and long-term disabili- ties. Beyond that, the setting of practice in public psychia- try is not just the short-term hospital, clinic, or emergency room but also the residential program, the street corner, the home, the homeless shelter, the laundromat, and the court- house. Clinical competence includes not only up-to-date knowledge but also a commitment to continue to learn and to strive for the highest quality of service using transparently reported quality metrics. An educational program requires a curriculum that is designed to meet the various needs of people cared for in public practice, in the settings in which they are encountered, with the highest quality of care.

In addition, this textbook has universal application. Although rooted in a particular institution of an academic department of psychiatry in a particular city and state, the educational program embodied here prepares students for success in public psychiatry anywhere in the United States. Needless to say, the target population of people with SMIs and/or SUDs share common features regardless of setting. Also, the American service system, although varying from state to state and location to location, shares fundamental features. It is for these reasons that the educational content


of the textbook is applicable in any setting, any system, and any educational program within the United States.

Finally, this textbook re ects an educational convic- tion that a system for public psychiatry ought to incorpo- rate a full range of community-based services: acute and long-term clinical, rehabilitation, primary care, addiction, public health, and forensic services and community-based supports. Perhaps the rehabilitative, community support, and public health aspects of the system deserve special emphasis because they are sometimes given short shri . Rehabilitative programs address disability, including psy- chological, social, and cognitive approaches. Community- based support focuses on increasing persons’ access to housing, jobs, school, faith communities, and other natu- rally occurring community activities. Public health com- ponents of the system include programs for prevention of substance abuse, early intervention in the course of illness, programs to establish and maintain wellness, attention and amelioration of health disparities among subpopulations, and commitment to maintaining a population perspec- tive in the development of the system and the allocation of resources.

As educators, the authors aim to kindle a ame of learn- ing while beginning to ll gaps in existing knowledge. ey aspire to spark a lifelong commitment to independent study through reading the literature and using independent judgment about new data. As a starting point, the bibliog- raphies in each chapter o er an entry into the literature. Small seminars in the local fellowship program in public psychiatry are designed to encourage critical thinking and discussion. Students are encouraged to evaluate new evi- dence and to conduct independent research, with a goal of achieving up-to-date, evidence-based practice throughout a career in public psychiatry. In addition to small seminars, the optimal pedagogical structure includes personal and clinic-based supervision and the creation of a community of curious, science-oriented, public professionals, all of which support this aim. In Chapter 16, a discussion of discipline- based and interdisciplinary teaching of public psychiatry resumes with respect to the elements of education and the important issue of workforce development.


e authors’ vision is to contribute through scholarship and teaching to the best possible education in public psy- chiatry. Using this textbook, the editors’ and authors’ aim is to prepare advanced professional students as outstanding

clinicians, as leaders, and, in some cases, as scholars. e goal is to equip them with up-to-date, clinical, person- centered knowledge and practice within a public service system. Given that the service system is broad, extensive, and complex, the authors believe that the most powerful force for the integration of services and supports is the well-educated, individual professional in public psychia- try. It is the professional clinician and leader—properly and well educated in caring for people with SMIs and/or SUDs; capable of advanced clinical practice in the pub- lic sector; knowledgeable in the value of residential and community supports; prepared for integrated health care, addiction medicine, public health, and forensic psychia- try; and expert in recovery—who connects the disparate parts of the system into a plan of care on behalf of and in collaboration with individuals living with SMIs and/ or SUDs and their families. e quality of care derives from the incorporation of all these elements into a com- prehensive, integrated, systemic, person-centered clinical process.


is textbook can be seen as a summary of the didactics in a curriculum for public psychiatry. Each chapter, alone or in combination, supplemented by citations from the litera- ture, might serve as a foundation reference for a seminar in a series that provides advanced, professional education in public psychiatry. Selected chapters can serve as the elements of a brief module in public psychiatry for begin- ning professional students (e.g., the Introduction, Systems, Public Health, Recovery, and the Conclusion).

e textbook has 19 chapters organized into four parts. Chapter 1 introduces the textbook, and Chapter 19 con- cludes it. e four parts in between are Part I “ e Service System of Public Psychiatry, Part II “System Integration Challenges in Public Psychiatry, Part III “ e Services and Clinical Competencies of Public Psychiatry,” and Part IV “System Development in Public Psychiatry.” When appropriate, the chapters o er brief histories of their topic. Most chapters consider quality metrics applicable to their domain, and most chapters cross-reference other chapters to emphasize overlapping and integrative themes. Some of the chapters use case examples to illustrate content. Each chapter includes an opening box summarizing the educa- tional highlights of the chapter. Finally, each chapter has a selected bibliography to serve as an entry into the literature for the purposes of in-depth self-education.


Part I, “ e Service System of Public Psychiatry,” con- tains three chapters. e service system is a distinguishing feature of public psychiatry. Chapter 2 o ers three per- spectives on this complex service system: (1) historical and developmental, (2) descriptive and structural, and (3) eco- nomic. It reviews the status of the “de facto” system, the management of the system, the tendency for skewed system development, and system transformation. e chapter iden- ti es the IDT as the fundamental unit of service in the sys- tem. e system is an essential constellation of resources and a context for practice in public psychiatry. Chapter 2 covers not only professional and scienti c initiatives but also polit- ical and economic policies that shape the service system.

Chapter 3 on recovery begins with a brief history of the recovery movement in psychiatry. Recovery is now one of the basic assumptions of public psychiatry. is chap- ter covers three major implications of recovery: (1) the provision of person-centered care, (2) the development of peer-provided supports, and (3) involvement of peers in assessments of quality and health care outcomes. e “discovery” of recovery is one of the most important devel- opments in public psychiatry in the past 50 years. e fun- damental process of person-centered care planning creates a framework for integrating clinical care of symptoms, reha- bilitation, and living in the community while responding to the goals and priorities of the person seeking help. It goes beyond symptom reduction to social inclusion and integra- tion into society.

Chapter 4 covers the crucial importance of community supports for practice outside the walls of the hospital. It emphasizes the value of the social inclusion of people with SMIs and addictions in recovery. It covers residential ser- vices, supported employment, supported education, and the techniques of psychosocial rehabilitation. It considers the need for all professionals in public psychiatry to integrate clinical care, community supports, and psychosocial reha- bilitation within a framework of person-centered care. It takes a “village” committed to community-based integrated care and social inclusion to establish an optimal system of services.

Part II, “System Integration Challenges,” includes four chapters regarding four major integrative tasks currently fac- ing the service system of public psychiatry: (1) integrated health care, (2) addiction medicine, (3) public health, and (4) forensic psychiatry. “Integration to the fourth power” is an expression that captures the exponential challenge ahead. Ultimately, the integration of plans of care for individuals seeking service is the most fundamental goal.

Chapter 5 addresses integrated health care and wellness as the latest expression of mainstreaming in public psychiatry,

a concept originating in the health policy debates of 1993. Most of the shortened life expectancy of people with SMIs and addictions is related to chronic conditions such as dia- betes mellitus, hypertension, cancer, and infectious diseases. is chapter considers the models, levels, and principles of integrated health care. It discusses medical homes, behav- ioral health homes, and the impetus given to integrated care by the A ordable Care Act (ACA).

Chapter 6 advocates for a greater integration of addic- tion medicine into public psychiatry and the leadership to carry this out. e chapter considers the service system of addiction medicine; the neurobiology and environ- mental factors in addiction; diagnosis, pharmacologic, and psychotherapeutic treatments; and dispositions for continuing care. It covers the evaluation and treatment of co-occurring disorders, and it argues for full equity of addiction services with mental health and primary care services. e ACA presents an opportunity to achieve bet- ter integration of addiction medicine into medicine and psychiatry, and public psychiatry may be instrumental in making this happen.

Chapter 7 argues that the incorporation of public health and population perspectives into public psychiatry is yet another key integrative task. e chapter provides de nitions of key concepts in psychiatric public health. It illustrates how public health data on morbidity, mortality, and disability can inform psychiatric practice. Public health interventions, or prevention, when integrated into practice, o er an ampli ed spectrum of practices and facilitate adap- tation to new models of practice-based population health. An ounce of prevention in public psychiatry has the poten- tial to better balance the service system through enabling reallocation of nite resources to reaching as many people in need of services as possible.

Chapter 8 discusses how the interdigitation of forensic psychiatry and public psychiatry supports essential skills and competencies that need to be integrated into pub- lic practice. Many people with SMIs and SUDs have legal problems. Forensic psychiatry has grown, especially in the era of deinstitutionalization, as a large, independent sub- specialty to address these issues. Forensic psychiatry pro- vides expertise to the public professional regarding special forensic hospitals, oversight of forensic populations, foren- sic community services, risk assessment, and collaborations with court, probation, and parole o cers.

Part III, “ e Services and Clinical Competencies of Public Psychiatry,” describes the services and competen- cies that are essential for public practice. e topics cov- ered are (1) children, adolescent, and young adult services, (2) early intervention for psychosis, (3) hospital services,


(4) ambulatory services, (5) outreach services and ser- vices for special populations, (6) cultural competency, and (7) global mental health.

Chapter 9 reviews the public system for children, ado- lescents, and young adults, where a developmental perspec- tive is essential for clinical practice and services. It covers a spectrum of special treatment considerations for these target populations. Youth who are transitioning out of the child system and into adult services, many of whom are already chronically ill and disabled, are particularly di cult to care for in the community. e chapter considers the challenges facing the child-focused system, including the long-standing need for better integration with the adult- focused system and the need for more manpower.

Chapter 10 presents early intervention programs for psychosis; these are probably the most important pro- gram developments in contemporary public psychiatry. ese interventions, which distantly echo ideas about community-based crisis intervention that were part of the launch of community mental health in the 1960s, shi the focus of public practice from the end stages of persistent ill- ness and disability to strategies for prevention of disability. Chapter 10 reviews the timing of interventions and rst- episode services for the purpose reducing the duration of untreated psychosis. As evidence accumulates and the ser- vice system tools up, early intervention is potentially game- changing for the service system of public psychiatry.

Chapter 11 presents clinical services in hospitals. It cov- ers acute care in emergency rooms and on inpatient units of general hospitals and long-term care in state hospitals, including forensic programs. It also reviews partial hospi- talization. It elaborates on the IDT in the hospital setting, where team functions are codi ed in accreditation require- ments, hospital departments, and procedures. Skill in work- ing on an IDT is a core competency for professionals in public psychiatry, di erentiates them from solo practitio- ners in psychiatry, and supports this fundamental unit for the delivery of services in the system. Finally, this chapter discusses the hospital as a microcosm in which system vari- ables play out.

Chapter 12 reviews ambulatory services in both com- munity mental health centers and federally quali ed com- munity health centers. It breaks down ambulatory services into walk-in, continuing care, transitional care in and out of hospitals, and specialty programs. A broad, truly bio- psychosocial, clinical consciousness underlies the clinical competencies considered in this chapter. Professionals in public psychiatry are the transducers of the system for a person seeking services. rough creative and profes- sional plans of care, the professional in public psychiatry

helps to pull the system of services together for the per- son with SMI and/or SUDs. It is the personal encounter and the cohesion, management, and adaptation of person- centered plans of care for individuals developed by the individual clinician that lies at the heart of practice in public psychiatry.

Chapter 13 presents special outreach services and services for special populations. ese include homeless outreach; assertive community treatment; residential treat- ment programs; programs for those with traumatic brain injury; lesbian, gay, trans-sexual, and transgender services; veterans’ services; and elderly services. When public profes- sionals enter many of these domains, the white coat of the hospital usually is le behind and di erent rules of engage- ment and competencies are necessary. e chapter discusses clinical competencies in each of these domains.

Chapter 14 describes the cultural competence necessary for professionals in public psychiatry to engage e ectively and sustain in treatment people of diverse backgrounds. Cultural competence gures prominently in strategies for reducing disparities in the treatment outcomes for people from cultural or ethnic minorities. e chapter reviews special evaluation modules and general education as funda- mental strategies for preparing behavioral professionals to serve a wide range of populations. Person-centered care is a template for cultural competency. Cultural curiosity can be a lifelong pursuit that not only enhances practice but also can lead to considerable personal growth.

Chapter 15 introduces the burgeoning area of global mental health. Public psychiatry can be a pathway to global mental health and international practice. is chapter dis- cusses the right to treatment and the need for psychiatry to have an international perspective. e challenge of meeting the needs of vulnerable populations such as refugees and recent immigrants brings home lessons learned in interna- tional practice. e development of telemedicine in low- resource settings may have applications in rural settings at home or for special populations. ese examples suggest a useful, reciprocal relationship between global mental health and public psychiatry.

Part IV, “System Development in Public Psychiatry,” has three chapters focusing on education and workforce devel- opment, evidence-based practice, and administrative best practices for the service system.

Chapter 16 discusses interdisciplinary teaching of professionals in public psychiatry with an eye to work- force development. It describes the elements of teach- ing programs in public psychiatry, both as part of core, discipline-based education and also in advanced fel- lowships, using the Yale Department of Psychiatry as


an example. It emphasizes the value of interdisciplin- ary learning in advanced education programs, which are needed to address the inadequacies of core preparation. Only by attending to preparatory and continuing educa- tion in public psychiatry is it possible to adequately meet the eld’s future workforce needs.

Chapter 17 on evidence-based practice addresses another basic strategy for system development. New dis- coveries, the evaluation of services, and their translation into evidence-based practices move public psychiatry for- ward. is chapter emphasizes the need for training and delity monitoring and discusses challenges in implemen- tation, as well as implementation strategies. It reviews the use of technology to achieve the goal of evidence-based practice. ese topics are essential knowledge for scientist- professionals who aspire to evidence-based practice in the public system.

Chapter 18 considers administrative best practices in public psychiatry. e service system is only as good as its management at all levels, from the clinical team leader to the chief executive o cer. is chapter is predicated on this axiom and describes how to get the best out of the system and those who work in it. rough a variety of measures within the context of recovery-oriented, person-centered care, and practice-based population health, creative and e ective management provides ongo- ing stewardship for and development of the system. Acknowledging that “leadership is a relay race” current leaders must teach leadership to their junior colleagues, who in turn must develop and plan for their personal development as leaders.

Chapter 19 describes how the system of public psy- chiatry is in a state of ux. It discusses the major policies and variables that are driving development in the system, including insurance reform, new service delivery models, and variables reshaping practice. It suggests that public– academic partnerships can be powerful alliances for developing and sustaining the system. It also suggests that academic divisions of public psychiatry in departments of psychiatry are instrumental in achieving future develop- ment in the eld.


Public psychiatry is the safety net of services for people with severe and persistent mental illnesses and SUDs. Ultimately, the significance of public psychiatry is

found in the changed lives and hopeful futures of these people who are successfully supported as they recover in the public system. Take, for example, a young student whose life is disrupted by acute psychosis and who is successfully treated, receives cognitive training, and is supported by the psychoeducation of his or her family, thus paving the way for recovery rather than a lifetime of chronic illness. Or consider a single mother, threat- ened with the loss of her children unless her psychotic depression is treated. With successful treatment of her depression and delusions, and while attending a sup- port group for young mothers, she is able to organize her daily life, establish a stable place to live, and care consistently for her children. Or consider a woman with an addiction who is precariously holding on to a job that her whole family depends on. With treatment, she can attend work regularly and productively. Although not all interventions in public psychiatry are fully success- ful, and there is much to learn and improve, these few examples illustrate the crucial value of public practice in the lives of those it serves.

It is possible and important to conceptualize the sig- ni cance of public psychiatry not only for the individual, but also for the community. Recent tragic events involv- ing gun violence and public health problems in American society dramatize the challenges to be addressed. Public psychiatry, among other professional disciplines, has a role to play in solving these challenges, and education in public psychiatry supports this role. Integration of knowledge and practice in public psychiatry is critical in addressing the chal- lenges of isolated, young adults falling into psychosis or of suicide among young adults and military veterans. Public health strategies and the public system of care help to trans- form psychiatric practice so that it focuses more on preven- tion, when possible, and early intervention to address these problems.

Another perspective on the signi cance of public psy- chiatry is the enormous size of the enterprise. In 2009, about half of all mental health and substance abuse expen- ditures were in the arena of public psychiatry (combined cost to Medicaid, state agencies, Social Security Disability Insurance, and federal block grants; see Chapter 2, Figures 2.1 and 2.2). According to data from the Surgeon General’s 1999 report on mental health, 2% of the American population received care that year in the public sector, out of the 15% of the population receiving mental health care.9 Although larger in comparison with other professional groups, 40% of psychiatrists work full or part time in the public sector. Under the auspices of the ACA, the number


of behavioral professionals and the entire enterprise will continue to grow because public psychiatry plays a key role in managing the vast increase in access to services through Medicaid for behavioral disorders.


is textbook strives for excellent, comprehensive, inte- grated, advanced, professional education in public psy- chiatry. is chapter introduces the textbook by providing de nitions of public psychiatry, the target population of people with SMIs and co-occurring or independent SUDs, and the service system. It discusses the special clinical com- petencies of public practice, and it reviews the educational principles that guide the book’s various chapters while pre- senting the book’s organization and content. e authors conclude that the present is a time of great signi cance for public psychiatry, given its critical role in the lives of people with serious, persistent behavioral disorders and disabili- ties; its size as part of the behavioral health care enterprise; and its expansion under health care reform.


1. Brown DB, Goldman CR, ompson KS, Cutler DL. Training psy- chiatrists for community psychiatric practice: guidelines for curricu- lum development. Community Ment Health J. 1993;29(3):271–283.

2. Ranz JM, Deakins SM, LeMelle SM, Rosenheck SD, Kellerman SL. Core elements of a public psychiatry fellowship. Psychiatric Serv. 2008;59(7):718–720.

3. Jacobs SC. e signi cance of public psychiatry and an overview. In Inside Public Psychiatry. Shelton, Connecticut: Peoples Medical Publishing House; 2011:1–19.

4. Schimar AP, Rothbard AB, Kanter R, Jung RS. An empirical lit- erature review of de nitions of severe and persistent mental illness. Am J Psych. 1990;147(12):1602–1608.

5. Staruss JS, Hafez H, Lieberman RP, et al. e course of psy- chiatric disorders, III: longitudinal principles. Am J Psych. 1985;142(3):289–296.

6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.

7. Yedidia MJ, Gillespie CC, Bernstein CA. A survey of psychiatric residency directors on current practices and preparation for public sector care. Psychiatric Serv. 2006;57(2):29–43.

8. Steiner JL, Anderson N, Belitsky R, et al. In: Jacobs SC, Gri th EEH, eds. 40 Years of Academic Public Psychiatry. West Sussex, UK: Wiley; 2007: 159–174.

9. US Department of Health and Human Services. A Report of the Surgeon General. Rockville, MD: USDHHS, SAMHSA, CMS, NIH, NIMH; 1999.






Selby C. Jacobs, Andres Barkil-Oteo, Paul DiLeo, Patricia Rehmer, and Larry Davidson


• Since 1963, ve periods of development have shaped the system of public psychiatry: community mental health, community support systems, mainstreaming, transformation, and health care reform.

• e system includes a wide array of services and supports for people with serious mental illnesses (SMIs) and substance use disorders (SUDs), varying from state to state and locale to locale as a function of state policies and local stewardship. e broad system structure with multiple components is necessary to meet the large spectrum of individual needs of people served by the system.

• Economic and scal policies repeatedly have been instrumental in shaping the system of care, in some cases skewing the system toward particular modalities of treatment and care.

• e mission of serving people with SMIs and addictions uni es the system of public psychiatry.

• e “de facto” system of services for people with SMIs and addictions is fragmented and midstream, undergoing a process of transformation to recovery-oriented care and system policies in the face of a wide expansion of access to services, the emergence of new service delivery models, and changes in practice as a result of the A ordable Care Act.

• System knowledge is essential for successful practice in public psychiatry.


is chapter sets out to answer three questions about the service system of public psychiatry. How did it develop over the modern era since 1963? What does it look like now? How is it nanced? e chapter ends with a discussion of the present status of the system, the management of the sys- tem, and the need to advocate for certain components of the system.

In 2003, the US Presidential New Freedom Commission on Mental Health described the system of services for pub- lic psychiatry as a “patchwork relic” in a state of “shambles.”1 Since then, the system has continued to evolve as a result of a transformational agenda recommended by the New Freedom Commission and guided primarily by the Substance Abuse and Mental Health Services Administration (SAMHSA). As

well, health care reform through enactment of the A ordable Care Act (ACA) in 2010 added impetus to system change. e primary challenge of this chapter is to describe this “de facto system,”2 one characterized by disorganization and lack of internal coherence.

A central thesis of this chapter is the proposition that a distinguishing feature of public psychiatry is the service system in which practice takes place. e system is a constel- lation of resources that supports practice. It is essential for professionals in public psychiatry to understand the system and work as e ectively as possible within it while also con- tributing to ongoing e orts to improve it. e cumulative knowledge of the service system, derived from clinical expe- rience and applied in service of people with serious mental illnesses (SMIs) and substance use disorders (SUDs), is a de ning characteristic of professionals in public psychiatry.


For learning purposes, this chapter utilizes three per- spectives on the public system of care. One focuses on the history and evolution of policy over the past 50 years, since 1963, when Congress enacted the Community Mental Health Centers Act during the Kennedy administration. e second perspective describes the structure and compo- nents of the system. e third perspective is a review of the nancing of public psychiatric services. Having already said that the system is disarticulated, is there a unifying concept for understanding the system? is textbook suggests that the mission of public psychiatry to serve people with SMIs and addictions is the overarching concept that holds the system together. Also, this mission is the criterion by which the system ultimately must be judged.

Chapter 1 served as an introduction to the service sys- tem by providing de nitions of public psychiatry, the target population, and the system itself. is chapter builds on that introduction. Subsequent chapters included in Part I of the textbook expand on essential components of the system, such as recovery, community-based supports, and public health.


Over the past 200 years, several important landmarks define major eras of development in the history of pub- lic psychiatry in the United States. Many of the service system elements created in each era remain as residual parts of the complex service system today. In 1813, dur- ing a time when many people with mental illnesses were imprisoned or confined in alms houses, the Quakers opened Friend’s Hospital in Philadelphia. This institu- tion was based on the belief that people with mental ill- nesses could lead “a moral, ordered existence if treated with kindness, dignity and respect.” The opening of this hospital ushered in an era of “moral treatment” in American psychiatry, a concept imported from France and England. Following the advocacy efforts of Dorothea Dix, a retired school teacher who had experienced per- sonal episodes of mental illness, the 19th century saw the widespread construction of both private and state hospitals, built largely in parallel. These state hospitals established the initial foundation of the early public mental health services system.4 Across the country, many state hospitals, such as Connecticut Valley Hospital in Middletown, Connecticut, and some private hospitals, such as the Institute of Living in Hartford, Connecticut, remain in continuous operation to this day.

In 1913, Cli ord Beers opened a clinic in New Haven, Connecticut, and launched a national mental hygiene movement that emphasized early intervention and ambu- latory care for children and their families. Beers su ered from manic-depressive illness, spent 2 years in Connecticut Valley Hospital, and was convinced that an alternative to long-term hospital care was necessary. His aim was to avoid chronic illness and the social breakdown that resulted from institutionalization. Mental hygiene clinics are still found in the community today as part of the public system of care for children. e Cli ord Beers Child Guidance Clinic in New Haven celebrated its 100th anniversary in 2013.

In 1963, President Kennedy proposed and Congress enacted the Community Mental Health Center Act, launching the modern era of public psychiatry. e mod- ern era can be seen as a progressive dialectic in response to the challenges of developing community-based services and supports to cope with the deinstitutionalization of patients from state mental hospitals. e modern era breaks down into ve main periods, with some overlap among them (see citation 3 for a more detailed discussion). Evolving policies on how best to serve people with SMIs and SUDs charac- terize each period and sow the seeds of the succeeding one, and the accumulation of these structures and services makes up the present “de facto” system of public services. No sin- gle period of modern public psychiatry “got it all right”; instead, an accumulation of services and community sup- ports accrued during di erent phases of modern develop- ment accounts for the current system (see Table 2.1).

In the rst period, the federally nanced community mental health movement brought about the construction of 675 community mental health centers over approxi- mately 20 years. One example is the Connecticut Mental Health Center (CMHC), which opened in 1966, in New Haven.7 e community mental health movement con- siderably expanded community-based ambulatory care for people with SMIs. e federally initiated community men- tal health movement, which spawned community psychia- try as a special area of psychiatric practice, was predicated on public health concepts of social determinants of health status, early intervention, treatment in the community, and continuity of care.4

Roughly coincident with the Community Mental Health Center Act, Congress enacted Medicare and Medicaid in 1965. Both programs provided reimbursement for acute psychiatric services in general hospitals and free- standing psychiatric hospitals. Notably, Medicaid legisla- tion, out of fear of cost-shi ing to the federal government by states, excluded reimbursement to institutions for men- tal disorders (IMDs), which were de ned as state-owned





Community mental health, 1963–82 Community support systems, 1982–93

Mainstreaming, 1993–2003 Transformation, 2003–2010

Health care reform, 2010–Present

Community-based services, public health and crisis intervention, large expansion of mental health professionals

Community-based services and supports for people with serious mental illnesses and addictions

Striving for parity in insurance bene ts for psychiatry and beginning integration into medicine

Recovery, focus on early stages of illness, and integration of mental health and substance abuse services

Access, accountability, quality, new service delivery models, integrated heath care, health homes, and population-based practice


and -operated hospitals. e nancial incentive provided by Medicaid reimbursement stimulated enormous growth in general hospital-based, acute psychiatric care that remains an essential part of the system today.

A second period of modern public psychiatry began during the Carter Administration with a Presidential Commission that laid the groundwork for community sup- ports for people with SMIs and SUDs. In 1980, Congress, in the last year of the Carter Administration, enacted the Mental Health Systems Act. With the election of Ronald Reagan in 1980, the sweeping recommendations of the Carter Presidential Commission on Mental Health for expansion of the national community mental health sys- tem, as embodied in the Act, were rejected. Nevertheless, a policy focused on people with SMIs and many innova- tive ideas survived in a National Plan for the Chronically Mentally Ill, published by the National Institute of Mental Health.5 Over the course of the ensuing decade, piecemeal policy and legislative initiatives took place on a federal level largely using Medicaid as a vehicle.6 At the same time, under renewed federalism, states, through their depart- ments of mental health, led local communities in develop- ing community-based services, supports, and systems. A key resource that emerged in this period, one largely nanced through the federal Department of Housing and Urban Development, as well as through local and state nanc- ing, was the development of community-based housing resources. is development was fundamental in mak- ing the transition from institutional to community care. In addition, emphasis was placed on system development through system-wide integration. During this time, replac- ing the earlier language of community mental health, “pub- lic psychiatry” emerged to characterize a system of services that included hospitals, clinics, rehabilitative services, com- munity supports, and housing.

During this second period, Medicaid—as a result of a series of legislative victories—began to reimburse for medi- cally necessary community-based services for people with SMIs and disabilities. ese included clinic-based services, case management, psychosocial rehabilitation, and assertive community treatment (ACT). ese services were provided together in local community mental health centers, many of which were products of the rst period of community men- tal health development. Periodic state budget de cits during the 1980s induced states and private nonpro t community mental health centers to turn to Medicaid for reimburse- ment of mental health services, a process known as “med- icaiding” services. By medicaiding, states became eligible for federal Medicaid matching reimbursement (FMAP). e logic was simple: if states could manage and control the volume of services they o ered, they could reduce their expenditures by 50% or more. Using Medicaid, private nonpro t agencies established a revenue stream to support sta and administration. Medicaid Supplemental Security Income (SSI), by providing income supports for people liv- ing in poverty, and Medicaid acute and ambulatory health insurance, including reimbursement for community-based outreach and supports, laid the foundation for community living for large numbers of low-income individuals with SMIs. By 2001, the two main payers of public services were Medicaid and state departments of behavioral health ser- vices.7 Medicaid was the single largest payer. e role of Medicaid nancing was so central that some refer to this period as one of Medicaid expansion. Success in this arena was a harbinger of mainstreaming, the next period of mod- ern public psychiatry.

is third period, which arose in 1993 out of the national debate on health insurance reform during the rst Clinton Administration, aimed to mainstream mental health insur- ance and social bene ts into existing federal entitlements,


welfare, and health programs.8,9 Mainstreaming in psy- chiatry provided an alternative to an expanded national system, originally stimulated by the community mental health movement, of special services for people with SMIs and SUDs. Mainstreaming echoed policy strategies that emerged from the community mental health debates of the early modern era. For example, during the health care debates of 1993, it became apparent that psychiatric ser- vices needed to integrate with medicine in order to achieve the bene ts of universal health insurance and end discrimi- natory health insurance bene ts for behavioral health dis- orders. A 1999 Surgeon General’s report on mental health, which described the system, questioned its cohesion, pointed out delays in implementation of evidence-based practice, and called for a reorientation of care to the promo- tion of recovery, was a landmark appearing near the end of this period.

Mainstreaming and the growth of Medicaid as a payer introduced payer status into consideration as a determinant of access to services. The effects were com- plex. A Medicaid entitlement enabled access to managed Medicaid plans of service through private nonprofit providers. Given scarce resources, access to state-owned and -operated services was restricted to avoid duplicate financing. The problem was that many people, such as single adults with SMI, were not qualified to receive Medicaid. Using Medicare as an example, another prob- lem arising from mainstreaming was disabled people on Medicare alone; these people had trouble accessing rehabilitative services because Medicare only covered acute care (see the later discussion on financing). Thus, payer status entered public practice as an important fac- tor to consider when developing individualized plans of care.

e fourth period of modern public psychiatry embraced transformation. is was an outgrowth of mainstreaming, launched by a 2003 report of the New Freedom Commission on Mental Health during the Bush Administration.1 Transformation shi ed attention to the integration of mental health into primary care, the integra- tion of mental health with substance abuse services, and the reorienting of services away from symptom reduction and rehabilitation of chronic disabilities to the promotion of recovery and social inclusion. All three of these goals remain prominent in today’s agenda of the public mental health services system. e SAMHSA put $100 million into trans- formation grants to states, one of which was received by the Department of Mental Health and Addiction Services of Connecticut. rough these grants, the federal govern- ment provided initiative to state and local authorities to

explore alternatives to a system that was considered to be in “shambles.”

e recovery movement that the Surgeon General’s report heralded and that gured prominently in the New Freedom Commission report historically developed as the vehicle for pursuing the rights and empowerment of people with mental illnesses and addictions. In the words of the 1999 Surgeon General’s report, recovery is the notion that “a person with mental illness can recover even though the illness is not cured” and de ned recovery as “a way of liv- ing a satisfying, hopeful, and contributing life even with the limitations caused by illness.” e recovery movement was indigenous to psychiatry (e.g., addiction services with 12- step programs), but it was also part of a mainstream medical movement toward ownership and consumerism in general health and welfare policy. In this sense, it was yet another example of the mainstreaming of mental health care with the rest of medicine. One potentially in uential policy out- growth of the recovery movement was the development of the concept of a recovery-oriented system of care (ROSC), a concept initially launched in Connecticut in 2002 and then taken up and disseminated by the SAMHSA through its guidance for state systems. is idea of a managed system of complementary services and supports integrated through the vehicle of individualized, interdisciplinary recovery plans developed in collaboration with the person and his or her natural supports, is now the leading policy direction supported by the US government. As a step further down the road in pursuit of the full rights and empowerment of persons with SMIs and addictions, the promotion of social inclusion and full citizenship for what is increasingly being recognized as a marginalized population is now being pro- posed as a next iteration of the ROSC.10

e h and present period of public psychiatry openedinthe rsttwodecadesofthe21stcentury.Itgrew out of the crowning achievement of mainstreaming: the federal enactment of parity for psychiatric insurance ben- e ts. Central to these developments was the elimination of restrictive insurance bene ts and prejudicial cost-cutting procedures in the management of mental health insurance and services. e enactment of health care reform in 2010 addressed the plight of uninsured persons through a man- date for universal insurance coverage, the establishment of community insurance ratings, and health insurance subsi- dies for people living in poverty. e ACA was a landmark achievement for increased access to mental health and sub- stance abuse services 11. Since then, most of the new poli- cies and structures in health care stem from and support the objectives of access expansion, accountability in provi- sion of care, integrated health care, population health, and


quality of care. e implementation time table of health care reform is 9 years, and it is still playing out. e ACA provides a vehicle for accelerating the implementation of key components of recovery-oriented care through its focus on person-centered medical homes, consumer choice and peer services, and the deployment of health navigators, which many see as a primary role for peer sta in the future. (Further discussion of the ACA is presented in the nal chapter, which considers directions for future service sys- tem development.)

On the heels of the ACA, Congress enacted and President Obama signed into law the Excellence in Mental Health Act of 2014. It is the single most important federal initiative speci c to mental health since 1963, and it adds to the impetus for change in the current period of system development under the ACA. e Excellence Act pro- vides for demonstration projects in eight states. It creates criteria developed by the federal Department of Health and Human Services for Certi ed Community Behavioral Health Clinics (CCBHCs), which will be certi ed by states. e Act requires that CCBHCs o er a speci c set of services and that states develop a prospective payment system for reimbursement under their Medicaid plans. Reimbursement is essentially cost-based, which provides an enormous incentive for scally strapped agencies with revenue-driven budgets to comply with the requirements of the act. Within this framework, CCBHCs may become important vehicles—along with other new service delivery models (see Chapter 19)—for meeting the requirements for expanded access to mental health and addiction services created by the ACA.

When all the contemporary developments are said and done, it is conceivable that some people with SMIs and addictions will continue to fall through the cracks. Transitionally, probably 5–8% of the population will remain uninsured, mostly undocumented individuals and those moving on and o Medicaid or having di culty navi- gating insurance exchanges. ese individuals will need to be served through a publicly funded grant system. is is a critical role, one that state departments of mental health and addiction services will continue to play.

Going forward, the variety of factors discussed in this section will further shape public psychiatry, forging yet another version of the “de facto” system of services. Over the past generation, ve major and interrelated themes have dominated policy and development: (1) mainstreaming of insurance bene ts, (2) parity of insurance bene ts, (3) the integration of mental health and primary care through medical homes and accountable care organizations, (4) the values of recovery and social inclusion of people with SMIs

and addictions, and (5) improved access to care. ese themes will continue to project into the future.


is chapter shi s now from a historical, evolutionary policy perspective on the system of public psychiatry to consider the question of what the de facto system looks like today. is section provides a description of the struc- tures and components of services in the current system. According to the old anatomical dictum, “structure is des- tiny,” the structure and components of the system deter- mine how it functions and, ultimately, what the clinician can do within it.

At the outset, it is important to appreciate that there is no single, universal system of care for public psychiatry in the United States. As noted in Chapter 1, the system intends to be universal and generic only at the federal level. For example, Medicare, as a funder of care, operates at this level. At the state level, considerable variation exists among state authorities for mental health and addictions; how much is invested in the system also varies by state, not to mention the variation in state Medicaid and demonstration programs. Considerable variation also exists at the local, county, and city levels related to local agency development and decisions. e array of services available in each locale is a function of inputs from all these levels. More important than the particular description of services in this section is the conceptual framework employed here for thinking about the system.

To anchor the description of services in a concrete exam- ple, this section presents an overview of the system extant at the CMHC in the city of New Haven, Connecticut. e system described here has many basic similarities to all systems in all states and localities, and it has many unique features as well. One di erence from many systems is that county government plays no role in Connecticut’s mental health services system. Also, Connecticut, unlike many other states, separates adult and child services into two inde- pendent state agencies. Although a full range of adult and child services exists in Connecticut, this division of state agencies adds yet another wrinkle to the system. Finally, Connecticut expends more dollars per capita for behavioral health services than most other states, and it has invested more of its state dollars in recovery supports by decreasing overreliance on acute care.12

In the description that follows, it is interesting and use- ful to compare the service system for public psychiatry to


the federally funded system for primary medical care. e state structures for mental health and addiction care make public psychiatry unique in comparison with primary care. Whereas states have departments of public health for gen- eral medical purposes, their role is generally limited to licensing, the collection of public health data, establishing prevention programs such as vaccinations, and generat- ing statistical reports. It is the state departments of mental health and addiction services, engaged as they are in pro- viding services, contracting for services, and stewarding the system, that make public psychiatry unique in comparison with primary care.

Finally, a major agenda of the ACA is the integration of primary care and public psychiatry through health homes and accountable care organizations. It will be help- ful moving forward to have a basic idea of the system of community-based primary care to better appreciate that integration.


In all states, the system of public psychiatry is strati ed at the federal, state, and local levels. e strati cations are both independent and connected through policy and fund- ing mechanisms.


At the federal level, the SAMHSA shapes national policy and innovates by means of service demonstration projects. An example of a demonstration project is the recent grants to local community mental health centers to create well- ness centers to address the shortened life expectancy of people with SMIs. e SAMHSA is made up of three parts: the Center for Substance Abuse Prevention (CSAP), the Center for Substance Abuse Treatment (CSAT), and the Center for Mental Health Services (CMHS). Each focuses on its cognizant area. e SAMHSA corresponds to the Health Resources and Services Administration (HRSA) for primary care.

Another key federal agency is the Centers for Medicare and Medicaid Services (CMS). ese centers administer Medicare and Medicaid policies. For Medicare, the fed- eral agency operates reimbursement mechanisms. is task is relegated to the states for Medicaid, and there is great variation from state to state. ese federal agencies nance the system of public psychiatry in each state. In Medicaid, states have considerable freedom to de ne policy and implement operations through their state plans written by

their Medicaid agencies and reviewed by CMS. States can engage constructively with the federal agencies or try to thwart them.


At the state level, most states have a department of mental health services and SUDs that either stands alone or is a divi- sion of an umbrella, superordinate human services agency. For example, Connecticut has an integrated Department of Mental Health and Addiction Services (DMHAS), which is a cabinet-level state agency.

Many states, due to budget stringency, have down- sized their departments of mental health and switched state-funded programs to Medicaid. Some have closed their state hospitals and contracted for community-based services while maintaining some specialized programs, such as forensic services. In Connecticut, for example, the DMHAS manages one state-owned psychiatric hospital (reduced from ve) and four community mental health centers. It also contracts with 17 private, nonpro t com- munity mental health centers across the state to provide ambulatory care and community supports to people with SMIs and substance abuse disorders. With regard to special populations, DMHAS is responsible for both hospital- and community-based services for people aging out of child ser- vices (because of the split in state agencies mentioned ear- lier), people with traumatic brain injury (TBI), or people with sexual disorders. DMHAS also provides forensic psy- chiatry services that include a forensic institute with hospi- tal beds, consultation to courts, evaluations of competency to stand trial, monitoring of individuals under not guilty by reason of insanity (NGRI) judicial decisions, jail diversion, and transitional services for people coming out of prison. Connecticut has been slow to “medicaid” services, and thus DMHAS remains a prominent player in public mental health policy and services.

All states have a state Medicaid agency; in Connecticut, this agency is the Department of Social Services. Within federal guidelines and according to a state plan approved by the CMS, these agencies administer Medicaid policies and bene ts for people living in poverty, single mothers with children, and disabled people living in poverty. Some people are “dually eligible” by virtue of having a disability, qualifying for Medicare, and also being poor enough to qualify for Medicaid. Medicaid sets reimbursement rates and pays for services. Under the ACA, which expands Medicaid to uninsured populations, state Medicaid agen- cies play a growing role in the public psychiatry service system.



Given the complex evolution of the system in response to various federal, state, scienti c, professional, politi- cal, and economic forces, the best perspective on a sys- tem o en is from the bottom up rather than top down. Each person with a SMI or SUD has di erent needs, and a spectrum of services is needed to meet those particu- lar needs. Local agencies strive to make these two service spectrums converge. Community mental health services o ered through local agencies correspond to the primary care services o ered by federally quali ed health centers (FQHCs).

At the local level of service, while service delivery has entered a period of major transition under the ACA (see Chapter 19), three models of service delivery have become well established in the past 25 years. ey are (1) state-owned and -operated community mental health centers, which ourished in the rst period of modern public psychiatry up until 1982; (2) the spectrum of private nonpro t men- tal health centers, which grew during the 1980s, stimulated by new sources of Medicaid reimbursement; and (3) mental health services in primary care FQHCs, which expanded con- siderably a er enactment of cost-based reimbursement for FQHCs in 1989. Each corresponds roughly to the rst three major periods of development in modern public psychiatry.

ere are fundamental similarities in the missions of the three models, but there are di erences as well. First, both state-owned and private, nonpro t behavioral agencies are tightly tied into the system of community supports, psycho- social rehabilitation, and outreach services. In general, com- munity health centers are not, which limits their ability to provide comprehensive services to the most disabled parts of the population. Second, although the integration of primary care and behavioral health is a challenge for all three, com- munity health centers have well-developed primary care as a foundation on which to build. Generally, the other two, not having in-house primary care services, face serious chal- lenges in how and where to develop these services. ird, community health centers and private, nonpro t behavioral health centers can build and grow their budgets with reve- nue streams largely derived from Medicaid fees. For commu- nity health centers, Medicaid revenue is cost-based, which is a distinct advantage. For private, nonpro t community mental health centers, revenue is not cost-based, it makes up a smaller proportion of their total budget, and it o en is supplemented with grants for services from state authorities. State-owned community mental health centers may collect fees for service on a sliding scale; however, their budgets come from state general funds and are usually independent of fees.

e governance of state-owned and -operated agencies is a state authority. By contrast, private, nonpro t community mental health centers and public community health centers have autonomous agency boards. Finally, depending on the health insurance bene t, each of the three serves somewhat di erent segments of the population of people with SMIs and addictions. Community health centers primarily serve those on Medicaid, with some exceptions. State-owned community mental health centers principally serve those on state assistance or without health insurance bene ts. Private, nonpro t community mental health centers straddle these poles, given their hybrid budget structure.

A Description of Local Services

is section focuses down on the system, turning again to Connecticut to illustrate an array of services at the local level. In Connecticut, there are four state-owned, community mental health centers. One is the CMHC. Although the CMHC has some unique features, it shares in common with other state-owned and private non- pro t agencies the task of mounting an array of services to meet the needs of the surrounding population it serves. e CMHC, in addition to being state-owned, is also a major training institution for the Yale Medical School Department of Psychiatry. As such, it represents a public– academic partnership among the State of Connecticut, Department of Mental Health and Addiction Services, and Yale University.

e CMHC, as a continuously functioning community mental health center since 1966, illustrates a thoroughly developed, wide array of clinical services and supports ranging from the hospital to a network of community- based services and supports including peer support. As a state-owned and -operated facility not subject to shi s in funding sources (but still subject to recurrent periodic bud- get stringency), it has been able to maintain most essential services over the years. On each of the services, interdisci- plinary teams (IDTs) of physicians, psychologists, nurses, social workers, rehabilitation therapists, and peer sta collaborate to o er comprehensive bio-psychosocial care. Subsequent chapters of the textbook provide expanded expositions of the services listed here. ose services in parentheses are operated by other institutions with which the CMHC maintains collaborative agreements:

• Acute and intermediate term hospitalization for adults

• (Acute hospitalization, adult and child, through the general hospital)


• (Long-term hospitalization in a state hospital)

• (Long-term care through local nursing homes)

• (Step-down partial hospitalization, intensive outpatient)

• Ambulatory outpatient care, both adult and child

• Early intervention in psychosis

• Addiction services

• Co-occurring mental health and substance abuse services

• Forensic psychiatry evaluations and consultations

• Community-based forensic, clinical services

• (Emergency services through the general hospital emergency department)

• Urgent care, crisis intervention including mobile crisis evaluations, and brief treatment

• Assertive community treatment

• Vocational rehabilitation

• Psychosocial rehabilitation

• Case management

• Community supports

• (Residential services, both child and adult), supported by clinical teams

• (Home-based services by visiting nurses)

• Outreach to people who are homeless

• Peer-delivered supports

• Integrated primary care through a Wellness Clinic

• Disaster readiness and critical incident stress management

• Services for special populations such as those with traumatic brain injury

• Young adult services

• Child ambulatory services (child guidance clinic)

• (Foster care services through the state agency)

• Consultation to nursing homes

• Home-based services for people leaving nursing homes


is spectrum of services grew during the modern era of public psychiatry as each period of development empha- sized particular aspects of care. is broad array allows exible, personalized planning of care for individuals and families. At the same time, program capacity is lim- ited because balanced program development constrains resources in any particular area. It is incumbent on the local facility and its clinical teams to manage access and maintain movement to the extent possible through the system.

Compiling a list of services also serves as a vital step in a needs assessment process for local agencies. Each local agency has amassed a unique array of services over the years depending on how long it has been in operation and what inputs it receives from federal, state, and local sources. A list helps to identify gaps. It also reinforces an understanding of the broad array of services needed, and, combined with local community and population needs assessment pro- cesses, it plays an important role in the maintenance and development of the service system (see Chapter 18).


Among the broad array of services and supports needed to adequately serve a variety of people, residential supports (discussed more in Chapter 4) are particularly important in the public service system. ey characterize the profound change seen in the system over the past 50 years as it dein- stitutionalized the care of people with SMIs. Development of residential resources began in the 1980s for several rea- sons: they served as a low-cost alternative to hospitaliza- tion, as step-down placements for people coming out of hospitals, and as placements for people who were homeless. Although supported by clinical teams (although not a clini- cal service per se), residential supports are now an essential platform for community-based care.

Again taking the CMHC as an example, for years, the city-wide New Haven Continuum consortium, co-chaired by mental health professionals from the CMHC, conducts a census of persons who are homeless, assesses needs, and col- laborates on annual grants for supportive housing from the federal Department of Housing and Urban Development. Federal Section 8 funding for low-income people supple- ments the supportive housing program. ese federal sources supplement investments made by the State of Connecticut using general fund dollars in supportive housing.


In recent years, “housing rst” programs provided evi- dence that initial or intensive clinical services sometimes were not needed to reduce readmissions or incarceration. It was discovered that stable housing arrangements could be achieved by persons with SMIs when they were o ered their own apartment with on-site support.13 e implica- tions of housing rst for the identity of the service system are profound because the essential problem addressed is the lack of adequate living arrangements for people coming out of hospitals and the social blight of homelessness, not symp- toms of mental illness. Clinicians o en viewed the task of nding a residential placement for patients as an adjunctive social variable in making a plan of care. e opposite proved true for many people with SMIs. Under this view, the hos- pital and clinic were no longer the center of the system. is perspective represents a seismic shi for the CMHC, which rst applied for accreditation in 1984 under the hos- pital standards instead of behavioral standards of the Joint Commission on Accreditation of Healthcare Organizations.

As a nal note, it is useful to consider both the his- torical development of the system and the levels of care as described in this section, given that increasing demand under the ACA may spur concern about rising costs. is could lead to a renewed sense of urgency about cost con- trol, managed care, and utilization review. In this scenario, aggressive utilization review could once again become a tool for aligning the resources of the public psychiatry sys- tem without paying attention the needs of particular people with SMI and addictions, and it could potentially threaten a balanced spectrum of evidence-based services that has taken years to build.


e IDT is the basic unit of organization for the service system of public psychiatry, although it is not unique to this eld. Rather, it is found in most medical and behav- ioral practice, with the exception of the solo practitioner in a private o ce. In public psychiatry, the IDT may be unique in the amplitude of team professionals and special- ists required to e ectively navigate a complex system. In public psychiatry, the IDT is the essential unit of organiza- tion that encounters the person with SMIs and SUDs. e plan of care for each person draws on an array of services o ered through the IDT to meet particular needs; the IDT and plan of care put the system in service of the individual seeking help.

e IDT is made up of physicians, nurses, psycholo- gists, social workers, case managers, vocational specialists,

and peer specialists. Commitment to the mission and prac- tice principles, such as recovery and person-centered care, bind an IDT. Core competencies within each professional group may di erentiate the members of the team. ese dif- ferences are most o en complementary and t together in a package that enhances care for the service user. For example, physicians have biomedical skills; psychologists bring skills regarding psychological dynamics, personality assessment, and cognitive science; social workers are experts in under- standing and working within the social welfare system, especially for support services; nurses have special skills in hospital, residential, and home care; case managers assist e orts to put bene ts and resources in place; vocational specialists support adjustment to work; and peer specialists have special skills in navigating the care system; all work in collaboration with the service user.

Core competencies of team members may be redundant in several domains. Psychotherapy, which all of the profes- sional groups learn, is an example. In this instance, nding ways to assign the work on the IDT may be more competi- tive than complementary. ese potential con icts are o en sorted out by cost, as a result of what payers are willing to reimburse. In some cases, roles and responsibilities, such as risk assessment or civil commitment, are statutory; in this case, team members must respect statutory requirements. Algorithms for team decision-making, which acknowledge these issues and are discussed transparently by team mem- bers, are useful in working out relationships. ese will vary by setting, from inpatient to outpatient and out on the street.

e ability to work on an IDT is a core competency for mental health and addiction professionals in public psychiatry, di erentiates them from other professionals in psychiatry, and supports this fundamental unit for service delivery in the system.


is section provides a description of how the array of safety net services just described is nanced, the third ques- tion posed in the introduction.

Even as policy initiatives have introduced new services and the system of public psychiatry has grown during the modern era, it has faced periodic political and economic headwinds and cutbacks. During the rst wave of retrench- ment from the community mental health center movement of the 1970s, an early director of the CMHC wrote about the “politico-economics” of the system.14 Indeed, since then, and despite the stewardship of the system by SAMHSA


and many state authorities, politico-economic pruning has rede ned, truncated, and moth-eaten the system.

e nal common pathway of politics and economics is the reimbursement mechanism and the services that are covered. Each nancing mechanism insures or reimburses a particular and sometimes limited range of services, which in turn may open or restrict treatment options. e public service system, always faced with scal limitations, is very sensitive to the services covered by reimbursement. For community mental health centers, following sources of income to cover the costs of personnel and operations has substantially shaped the system; thus, it is useful to under- stand how services are nanced. ere is o en a dialogue between political/economic agendas and professional and scienti c policy initiatives. e 1980s presented a conspic- uous example, as federal retrenchment from community mental health occurred while major policy initiatives were pursued piecemeal under Medicaid and implemented by the states.

A recent publication o ered a view of the “economic anatomy” of American health care.15 Because mental health care has recently achieved parity of insurance coverage in the United States and is progressively integrated into gen- eral medical care, this analysis is pertinent, and this section begins to develop an “economic anatomy” of the system of public psychiatry.

rough their analysis, Moses et al. identify four major factors driving the growth of the medical economy: price of particular services, costs for professional services, drug and device costs, and administrative costs. In other words, it is not aging, chronic diseases, particular health insurance initiatives, or a variety of other factors that are o en cited. Sometimes, in con ict with each other, several additional forces catalyze this growth: (1) consolidation of health ser- vice delivery, (2) information technology, and (3) the rise of patients as consumers who choose the services they will use. Additional forces presently at play are (1) cost, (2) a focus on group or population health outcomes instead of individ- ual outcomes, (3) the substitution of social and economic goals for goals related to the needs of individual patients, and (4) the pressure of demand for services resulting from expansion of insurance and access to care under the ACA. Note that none of these factors is essentially professional, medical, or based on research data, yet they have a powerful potential to shape, if not distort, the system of care. is picture of the general medical care system serves as back- ground for a view of the economic anatomy of the system of public psychiatry. For example, in the later section “System Status, Management, Skew, and Transformation,” there is an example of how the soaring cost of pharmaceuticals

has dominated system economics without o ering signi – cant therapeutic advantage and to the exclusion of other evidence-based practices with proved e cacy in helping people with SMIs and addictions (e.g., cognitive behavioral psychotherapy, supported employment).

Virtually all the nancing mechanisms discussed here have been operating throughout the modern era of public psychiatry. ey have evolved considerably (e.g., mental health bene ts under Medicaid). Also, in each period of the modern era, particular mechanisms prevailed and largely set the course of development for the system. During the community mental health center period, federal fund- ing dominated in the construction and policies of com- munity mental health centers. During the second period, at the beginning of the Reagan administration, Congress rescinded the Community Mental Health Systems Act, and federal money, repackaged as block grants to states, fell dramatically. State general fund dollars prevailed in picking up the slack at rst, then Medicaid, jointly funded by the federal government and the states, grew as an essential payer for services. Over both these early periods, Medicare grew in importance for elderly and disabled people. Starting with mainstreaming in the 1990s, there has been a successful process of advocating for parity under Medicaid, Medicare, and, eventually, commercial health insurance under the ACA. Going forward, public bene ts and commercial insurance policies will shape the system of care.

As in the case of describing a local service system, this description of nancing draws on Connecticut as a concrete example. Whereas Medicare is universal, Medicaid policies vary from state to state according to state plans, and other state programs are locally determined.


Medicaid, enacted in 1965, is a national health insurance program for families and individuals with low incomes and resources. It is a means-tested program that is jointly funded by federal and state governments. It is managed by state Medicaid agencies in concert with policies negotiated with and approved by the federal CMS. On the state level, Medicaid agencies become counterparts to state depart- ments of mental health and addiction services. Medicaid covers a wide range of acute care and, notably, many long- term care, outreach, and community-based services for peo- ple with SMIs. In addition, Medicaid covers nursing home care, which is commonly used for discharge from the hospi- tal to avoid long-term hospital costs. States control the level of reimbursement under Medicaid, which, depending on the state, at times is so low (even below costs) as to discourage


participation by individual professional practitioners. Even in states that have increased levels of reimbursement equal to those of Medicare (such as Connecticut), professional participation remains low, not only because of the marginal reimbursement rates but also perhaps because of the special challenges of the patient population served in the public sector (see the Kaiser Commission report for a general dis- cussion of mental health care nancing and Medicaid).16


e State Children’s Health Insurance Program (CHIP) is a health insurance program for children in families with incomes that are modest but too high to qualify for Medicaid. It is administered by the federal Department of Health and Human Services through state Medicaid agencies.


Medicare, enacted in 1965, is a national health and social insurance program administered by the US government through its CMS. Medicare guarantees access to health care for Americans aged 65 and older. Younger people with disabilities and special populations such as people with end-stage renal disease or amyotrophic lateral sclerosis are also eligible for Medicare. Medicare Part A covers hospital costs. Medicare Part B covers ambulatory costs. Medicare Part D covers drug costs under managed pharmacy ben- e ts. Medicare’s health bene ts cover acute care. With the exception of the special populations just mentioned, these bene ts do not include long-term or rehabilitative services. For the Medicare bene ciary, the latter services are di cult to access unless a person is dually eligible (see next) or the service is underwritten through a state budget.

Dual Eligibility

Dually eligible people are those Medicare Part A and B recip- ients who qualify for a Medicare Savings Program (MSP) or for Medicaid bene ts. Many qualify for Quali ed Medicare Bene ciary (QMB) bene ts, which cover Medicare Part A and B premiums and Medicare deductibles, co-insurance, and co-payments, paid for by Medicaid. is arrangement provides full health care coverage. Essentially, the dually eli- gible population is both disabled and poor.

Many people with SMIs and addictions who are living in poverty are dually eligible and are provided access to a full range of acute and long-term care services covered by both Medicare and Medicaid. is population is very costly to

serve. Dually eligible people with mental illness accounted for 16% of the Medicare population in 2007 and for 27% of Medicare spending. Fi een percent of Medicare enroll- ees were dually eligible and accounted for 39% of Medicaid spending.


Each state annually appropriates money into budgets for human services, including mental health and addictions. Administered by free-standing state departments of men- tal health and addiction services or as departments under human services, these state funds cover a range of services and supports, including hospital care, ambulatory care, rehabilitation, residential supports, and services for spe- cial populations. In some cases, the services are provided through state-owned and -operated agencies such as hospi- tals or mental health centers. In other cases, the state o ers grants or contracts for a service. Generally, states build their general fund programs in a way to supplement or comple- ment those services reimbursed by Medicare or Medicaid in order to ll gaps and provide a full spectrum of services in each state.


Low-income adult Medicaid programs, formerly known as state administered general assistance (SAGA), provide a social safety net for people who are very poor and do not qualify for other types of public assistance. ese programs provide both income and health bene ts. Many states have eliminated these programs recently; however, 30 states still o er them to people who are poor, do not have minor chil- dren, are not elderly, and are not disabled enough to qual- ify for disability income. Although variation exists among the 30 states that o er general assistance programs, most recipients qualify for health coverage, generally through Medicaid.

Figures 2.1 and 2.2 summarize the components of public funding for services and place them in the context of overall funding for psychiatric services for both mental health and substance abuse services using SAMHSA data from 2012, the latest year for which data are available.16

Public funding combining Medicaid, Medicare, other federal funding (which includes block grants from the SAMHSA to states), and state and local funding is the larg- est source of nancing for both mental health and substance abuse services. It accounts for 60% for mental health ser- vices and 68% for substance abuse services. Medicaid is the



Other State and Local 15%

Out of Pocket 11%


New England

United States













Other Federal 5%

Private Insurance 26%

Other Private 3%







Medicaid 27%

* Includes Other Professionals, Nursing Home and Home Health Services.

Figure 2.3 Mental health and substance abuse services spending per person by region and service, 2005

variation among states regarding how much is invested in public psychiatry (see Figure 2.3).18

New England invests more than the national average in services. In contrast, many states in the Southwest and South invest less than New England, which brings down the national average and raises questions—given scarce state funding on average—about whether funding of the mental health and addiction services is adequate.



SSDI is a federally administered program that provides aid to people who are unable to achieve gainful employ- ment due to a permanent disabling condition. e Social Security tax nances SSDI. People must have worked in gainful employment and paid Social Security taxes long enough to achieve su cient work credits to qualify. e Social Security Administration adjudicates the existence of disability and eligibility for the bene t. Many people with SMIs fell ill a er su cient work history to qualify for SSDI, which provides income for them to live in the community.


SSI is a federal income supplement program funded by gen- eral tax revenues (not Social Security taxes). It provides cash to pay for basic needs such as food, clothing, and shelter to disabled adults and children who have limited income and resources. Individuals who are aged 65 or older, with- out disabilities, and who meet the nancial limits are eli- gible. Individuals who have worked long enough may also


$200 $300
MHSA Spending Per State Resident

$400 $500 $600 $700


Mental health expenditures by payer: 2009 (by millions of

single largest payer for mental health public services, and state and local sources are the largest funders for substance abuse services. If you combine Medicaid and CHIPs, which is sometimes placed under the state and local category depending on where it is managed, Medicaid is even more prominent. When data are available for 2014 and the years following, they will undoubtedly show Medicaid’s expand- ing role due to new enrollment under the ACA. Medicaid’s prominence explains why state Medicaid agencies, in con- trast to cognizant state departments of mental health and addictions, have a growing and perhaps dominant voice in setting policies regarding who is covered and what services are covered in public psychiatry. In addition, there is much

Figure 2.1


Medicare 13%


Other State and Local 31%

Out of Pocket 11%

Private Insurance 16%

Other Private 5%

Medicare 5%


Figure 2.2

Substance abuse expenditures by payer: 2009 (by millions of


Other Federal 11%

Medicaid 21%


Hospitals Physicians MH & SA Specialty Centers Retail RX Drugs All Other*


be eligible for SSDI or Social Security retirement bene ts. Many people with SMIs are eligible for this welfare bene t.


HUD o ers grants through an annual competitive bidding process for new construction, acquisition, rehabilitation, or leasing of buildings to provide transitional or perma- nent housing, as well as supports to homeless individuals and families. HUD also o ers grants to fund a portion of annual operating costs and grants for technical purposes. Many people with SMIs who are homeless are eligible for these bene ts and establish residences, with community supports, via the process.


Section 8, managed by HUD in conjunction with state Medicaid and public housing agencies (PHA), authorizes the payment of rental housing assistance to private land- lords on behalf of low-income households. It operates through several programs, the largest of which, the Housing Choice Voucher program, pays a large portion of the rents and utilities of eligible households. Housing subsidies are paid directly by the PHA to landlords on behalf of the par- ticipating family.


e Housing Assistance Fund Program is a state-funded program that provides for monthly housing subsidies to persons with a SMI on a temporary basis while an indi- vidual or family is on a waiting list for a permanent state or federal subsidy.


Using state general fund dollars, Connecticut has created more than 2,000 units of Supportive Housing through the establishment of the Interagency Committee on Supportive Housing to address the needs of the homeless population in the state. Connecticut Supportive Housing combines a ordable housing, most o en through a rental subsidy, with intensive yet exible supports for people with SMIs.

All these health and social welfare bene ts, either singly or in combination, enable people with SMIs and SUDs to live

in the community, outside of hospitals and nursing homes, as they utilize treatment and pursue recovery. e public psychiatry professional with a working knowledge of these bene ts can plan e ciently and e ectively for the care of the individuals they serve. Also, when the mental health professional is asked to support an application for a bene t or disability, it is useful to have a working understanding of the system.


Given both the federal and state sources of nancing for the public system of psychiatry, at times of budget stringency, federal or state authorities may try to shi costs from one to the other. Cost shi ing plays out through Medicaid in particular. It was the concern about cost shi ing that moti- vated the federal rule against reimbursement for IMDs when Medicaid was enacted in 1965. Another example is the “medicaiding” of services, which began in the 1980s. States faced with severe budget problems during this decade limited their general fund expenditures (in which they paid 100% of the costs) by shi ing to Medicaid (in which they paid 50% or less). Medicaid became a major source of sup- port for services for people with SMIs. Yet another example of cost shi ing may be developing, this one involving the risk of retrenchment in state general fund dollars when Medicaid is fully instituted as the payer of services for pre- viously uninsured people with SMIs and addictions. As a corollary, the federal government may retrench on block grants for the same reason. e risk for the service system is that a net loss of resources may occur, and the people needing services may be lost in the shu e. It is important to monitor this process to minimize this risk, through pro- visions for maintenance of e ort by states in federal/state Medicaid agreements. For example, the expansion of access under Medicaid as part of the ACA is nanced largely by the federal government in the rst few years a er 2014. As the state share rises in the future, it is likely that cost-sharing maneuvering between the states and the federal govern- ment will intensify. At this point, mental health advocates must pay attention.

is look at the “economic anatomy” of public psychia- try reveals a collage of multiple sources of funding and reim- bursement mechanisms for health and welfare services. is hodge-podge is the nancial foundation of the fragmented, de facto system of public psychiatry. No single level of gov- ernment or agency is in charge of striving for a coherent whole. is “patchwork relic,” supported by a multiplicity of sources, has motivated the call for a new federal agency


charged with coordinating policy for services to people with SMIs and addictions.12


Who is in charge of the system? What are strategies for man- aging the system? What is the current status of the system? How can the system be shaped to better serve people with SMIs and addictions? Are there distortions in the system? e next few sections set out to address these questions.

Obviously, no single person takes responsibility for the whole services system. In the large, complex, and strati ed system that exists, a variety of people take responsibility. Two essential ideas are worth emphasizing when addressing this question. First, at the lowest level, it is the professional in public psychiatry, working as part of an IDT and through individualized plans of care, who takes charge of the system on behalf of a person seeking care for a SMI or addiction. Second, the service user as the ultimate consumer of ser- vices, through governance structures, consumer choice of where to obtain care, involvement in quality control, and consumer satisfaction data, plays an essential and growing role as custodian and shaper of the system.


During the 1980s, the community system expanded the administrative and clinical leadership of local mental health authorities who were responsible for the management of the system in order to assure proper use of the multiple levels of care. en, rst in the private sector and eventu- ally in public psychiatry, payers hired managed care com- panies or administrative service organizations to manage utilization, improve e ciency, and reduce costs. Although savings could conceivably be applied to service expansion or development, in most cases, the savings went toward administrative costs or pro t. In response to the challenges posed by this new type of utilization review, the American Association of Community Psychiatrists developed the LOCUS tool for determining level of care as part of a utili- zation review.19

LOCUS brought clinical assessments and clinical ratio- nales back into the process of determining the proper level of care. LOCUS uses quanti able ratings on six dimen- sions of risk management, functional status, co-morbidity, recovery environment, treatment/recovery history, and engagement to place a person in one of six levels of care. e levels of care are, starting from the lowest, recovery/

health management, low-intensity community services, high-intensity community services, medically monitored nonresidential, medically monitored residential, and medi- cally managed residential services (i.e., hospitalization). e local array of services enumerated earlier ts into these cat- egories in obvious ways.


e primary purpose of this chapter is descriptive, not ana- lytic or judgmental. Indeed, there is no single, universal ser- vice system on which to render judgment. Each locale and situation is di erent, state by state and locality by locality. Nevertheless, a brief discussion of the current state of the public system provides perspective on how well it is doing.

As noted earlier, two recent national reports on the public psychiatry service system rendered judgments on it that give pause. One was the 1999 Surgeon General’s report, which referred to the system as “fragmented” and “de facto.” It noted that the public system had little logic or coherence and was instead an accumulation of develop- ments formed over the years. In 2003, the New Freedom Commission described the system as a “patchwork relic,” “in shambles,” and failing to meet the needs of recovering people with SMIs and addictions. No fundamental system change has occurred since these reports.

Adding insult to injury, the economic recession of 2009 and ensuing years led to deep budget cuts for services for people with SMIs and addictions. e National Association of State Mental Health Program Directors (NASMHPD) estimates that states cut public services by $4.35 billion from 2009 to 2012.20 at is $81 million per state on aver- age, although wide variation exists among the states with some, like Connecticut, cutting less and others more. Also, 4,417 state psychiatric hospital beds, 9% of capacity, have been eliminated. Many of the remaining beds are lled by patients under court order for evaluation or other forensic purposes. In addition, the American Hospital Association estimates that the number of acute beds for psychiatry in general hospitals has fallen by 32.5%. e number of gen- eral hospitals with psychiatric units has declined from more than 1,500 in 1995 to fewer than 300 in 2010. Forty percent of people with SMI and 60% of people with any psychiatric disorder go without treatment. e new asy- lums are nursing homes, emergency departments, jails, and homeless shelters,21 although the exact causes of this are still uncertain.22 ese budget cuts for services have occurred despite the knowledge that psychiatric disorders account for a substantial burden of disease in American society (see Chapter 3) and that mortality rates from psychiatric


disorders are high from suicide and untreated chronic med- ical conditions (see Chapter 3). It will take time to simply restore services lost to recent budget cuts and address this disarray in services. In the meantime, much of the manage- ment of behavioral health services is fundamentally the management of scarcity.

Two mental health policy experts concluded that, over the past 50 years (1950–2001), there has been improvement in the well-being of people with mental illnesses and that the population served was “better but not well.”8 Yet the system of services and the substantial—yet insu cient— investment in behavioral health care, along with de cient scienti c models for prevention, diagnosis, and treatment,22 has not delivered reasonably expected reductions in mor- bidity, mortality, and disability from mental and addictive disorders.23

e ACA and the Excellence in Mental Health Acts are the latest major health policy initiatives that will further shape the service system of public psychiatry. e “de facto” system under the ACA will feature a prominent role for new service delivery models (see Chapter 19). For example, the major source of treatment for depression may become the community health center.26. On the other hand, community mental health centers probably will continue to play a key role in caring for the most severely, persistently ill and dis- abled. Connecticut, for instance, stimulated substantially by the Excellence Act, is developing a model of behavioral health homes (a medical home with emphasis on a broader agenda for behavioral services) to o er persons with more SMIs more choices in care, with many of them being able to receive their primary care within traditional mental health settings. Interestingly, it is easy to see the potential for com- petition between primarily primary medical care agencies and primarily behavioral health care agencies. If so, the role of consumer satisfaction and consumer choice will become a big variable in determining the locus of care. On a state level, both departments of mental health and addictions, which have the requisite expertise in public psychiatry, and state Medicaid agencies will continue to share important scal and policy decisions regarding the system of public psychiatry.

Given the disorganized, uneven, and chronically insuf- cient resources of the service system for public psychiatry, the challenge for the practicing, public-sector professional is to know the system, take advantage of its strengths, try to compensate for its weaknesses, and advocate for adequate and wisely managed resources. It is essential to use knowl- edge of the service system to respond to people seeking ser- vices and help them access the system in whatever way is possible and right for them. In addition, given the “disarray”

in the service system, it is a challenge for professional service managers to sustain a broad spectrum of services to provide the range of options, including all evidence-based practices, needed by individuals at di erent points in the trajectory of serious and persistent mental illnesses or addictions. Finally, mental health professionals should advocate for resources allocated to e ective practices and for patients’ freedom of choice by o ering all evidence-based options, including psychosocial ones, in a balanced array of services. ese pro- fessional responsibilities are part of an ongoing obligation to establish a social priority for the least well o in the cir- cumstances of mainstreaming and health care reform.


roughout the modern history of the service system of public psychiatry, sometimes single-minded, telescopic policies or commercial zeal have skewed the system. Given nite resources, professionals in public psychiatry need to be vigilant and able to correct for such system distor- tions, which create an illusion of progress and can constrict practice.

For example, in the earliest stages of the modern era, emphasis on development of community-based services and early intervention was associated with relative neglect of chronically ill people deinstitutionalized out of the hos- pital and into the community. In the 1980s, single-minded devotion to creating community-based services for people with SMIs and addictions was associated with inattention to early intervention and hospital services. is eventu- ally led to a relative neglect of early stages of illness and shortages of acute, intermediate, and long-term hospital services. e emergence of Medicaid as a prominent payer during the 1980s and ‘90s led to increased access to public services for people on Medicaid; although this is desir- able, it also attenuated the focus of the public system on some needy people with SMIs and SUDs who were not on Medicaid.

Currently, despite a nagging shortage of hospital beds, there is improved overall balance in the system. Still, there is a “pharmacologic bias,” apparent in three prominent, inter- related problems persistent in the treatment of SMIs: exces- sive reliance on a limited number of antipsychotic medications at the expense of other e ective treatments27, nonadherence to evidence-based practices, and the crucial problem of access to care for people who need it. Whereas medically ill patients in the United States receive the rec- ommended care about half the time, the corresponding rate for people with SMIs is no more than 1 in 4.34 Rather than be consoled by the general inadequacy of medical treatment


in the United States, the eld of public psychiatry needs to ask itself, “Why is this happening? And can we do better?” Large comparative e ectiveness trials (like CATIE) dis-

credited the widely held belief created by incomplete data from pharmaceutical companies that newer, o en more expensive atypical antipsychotic medications are more e ective than older, less expensive ones.25 Yet, the only con- sistently superior medication is clozapine, and, ironically, it is widely underprescribed. Two reasons o en cited for this are the frequent blood draws required to avoid the risk of agranulocytosis and general side e ects like weight gain, constipation, and sedation. Other countries with similar compulsory lab schedules have higher prescription rates, and clozapine’s side e ects are not much di erent from the side e ects of the polypharmacy regimens that result when patients are not prescribed clozapine.

Over the past 15 years, psychotropic medication use in general and polypharmacy in particular have increased, with little indication of concurrent changes in patients’ illness severity, comorbidity, or outcomes as measured by burden of disease, mortality, or prevalence of disorders.24 Psychiatrists continue to prescribe some atypical anti- psychotic drugs despite their higher cost—some of them with increased risk for causing metabolic syndrome and diabetes—and with no demonstrated superior e cacy. To make things worse, fewer than 13% of patients taking atypi- cal antipsychotic drugs are screened for glucose imbalances and dyslipidemia, and only 3% receive follow-up laboratory tests. is has serious consequences for patients because iatrogenetically induced metabolic syndrome is one of the four main risk factors identi ed as a cause of early mortality in persons with schizophrenia treated with antipsychotic medications. Typical antipsychotic drugs have their side e ects as well, particularly the risk for tardive dyskinesia; however, recent reports found no di erences in the extrapy- ramidal side e ect rates between conventional and atypical antipsychotic drugs. To make things worse, people on atypi- cal antipsychotic medications are less likely to be prescribed adjunctive anticholinergic medication despite equivalence in terms of extrapyramidal side e ects.

Some evidence-based approaches (see Chapter 17) to SMI, such as cognitive behavioral therapy (CBT) groups for psychotic symptoms, supported employment, fam- ily psychoeducation, and supportive housing programs are underutilized. e schizophrenia Patient Outcomes Research Team (PORT) study, for example, found that, in the late 1990s, patients were receiving only 10–46% of the approved treatment interventions for schizophrenia; later studies con rmed these results. Constraints on men- tal health funding from Medicaid and state general funds,

coupled with increased spending on new and expensive medications, are responsible for this shortage in the deliv- ery of e ective treatments because they led to reduced funding for other evidence-based services such as housing, vocational training, and case management programs.25 Such situations not only limit the basic right of choice for service users, but also increase the cost of services by concentrat- ing treatment in a few interventions of limited e ectiveness. For example, 80% of the money spent on antipsychotics is allocated to only three medications (although this situation may change, given that two out of the three medications are in the process of becoming available in generic forms). Still, there is no guarantee that the savings in cost will be used to provide other, more e ective treatments.

In an era of person-centered practice (see Chapter 3), personal choice should be highly valued, and the right to be o ered all evidence-based interventions, both pharma- cological and psychosocial, must be assured. Behavioral professionals must serve as guides in selecting high-value options for each individual based on the evidence, clini- cal expertise, and patient values. Given nite resources, in order to support such practice, it is important to strive for balance when choosing from an evidence-based array of ser- vices to meet the entire needs spectrum of individuals with SMIs and SUDs. Furthermore, it is important for behav- ioral professionals, who take note of skew in the system, to use this understanding to advocate for constructive change, consistent with the core mission of improving care for peo- ple with SMIs and addictions. Optimally, professionals in public psychiatry need to steward the system: to be not only creative clinicians who shape their practice wisely, but also mangers, advocates, and agents of change.


Given the challenges facing the service system of public psychiatry, what can be done to improve and expand it, to transform it as the New Freedom Commission called for, with an eye on the original target population of vulnerable people with SMIs and SUDs? is chapter begins a discus- sion of system transformation. e nal chapter picks it up and addresses the full spectrum of factors now active in shaping the public system of services. ese include policies regarding insurance reform, new service delivery models including integrated health care, and new models of prac- tice, accountability, and quality assurance (see Chapter 19).

Optimal transformation depends on engaging the whole service system from top to bottom. It requires both clinical and population perspectives (see Chapters 3 and 18). Most behavioral professionals are deeply trained in a


clinical perspective that places the needs of a particular per- son above everything else. e challenge for a system man- ager is to develop a community and population perspective and integrate it with the clinical one. Using a population perspective, system managers must take an overview of the system, maintain a balanced spectrum of services, and implement innovative practices as they are developed and proved.

Translating into practice those innovative services sup- ported by evidence is essential for transformation. (Sub- sequent chapters of this textbook discuss evidence-based practices in several domains of practice; Chapter 17 more generally discusses evidence in public psychiatry.) Scienti c discovery from clinical trials and services research is only part of the process. e challenge is to shorten the estimated 17 years between discovery of evidence-based practices and implementation in the eld. is goal requires not only an eye to new, evidence-based practices as they develop, but also training clinicians in new interventions and using creativity in nding new resources or reallocating existing resources where the demand does not justify current levels of service. e objective is a range of services that meets the needs of a variety of individuals with SMIs and addictions.

us, coincident with innovation in services is the need for workforce development and training (see Chapter 16 on education). For innovative practice to take hold and gure in person-centered care, frontline clinicians must be part of the equation. E ective leadership at all levels of the system—from chief executive o cers, to agency policy directors and medical directors, down to the clinical team leaders—is essential. Advanced training in public psychia- try, including preparation for leadership and management, supports this task.

Also, it is important to note that consumer empower- ment and consumerism play an increasingly important role in system transformation and the allocation of services (see Chapter 3). Data on cost and quality of services, collected, managed, and publicly accessible in real time, will provide a foundation for documenting consumer satisfaction and supporting consumer choice. Contemporary information management resources make this possible. In addition, sys- tem leaders must incorporate service users and family mem- bers into every level of governance and operational roles in the system.


System knowledge, acquired through special training, dif- ferentiates professionals in public psychiatry from their

counterparts in general psychiatry. e “system” as described in this chapter gures prominently in teaching programs for professional students of public psychiatry. Learning about the system occurs not only in didactic seminars, but also in placements in various parts of the system, in supervision, and, on a daily basis, in working out comprehensive plans of care with individuals served by the system. e central thesis of this chapter is that the system—knowing it, work- ing in it, using it, managing it, developing it, and sustaining it—is one of the most important features of public psychia- try that distinguishes it from the rest of psychiatry.

System knowledge, together with understanding of the special needs of the key target population of people with SMIs and addictions, is the foundation for e ective practice in public psychiatry. Working within an IDT, professionals in public psychiatry, drawing on an integrated view of care and a thorough knowledge of the strengths and weaknesses of the service system in which they work, are lynchpins in creating comprehensive, coherent, integrated plans of care in collaboration with persons in recovery that will enable them to access and navigate the system of services. For the purpose of making accessible as many necessary services as possible, knowledge of the system is essential. A transition in practice is under way that will lead from procrustean programs of service that are o ered practically to everyone to person-centered care, in which elements of service are mobilized into individualized plans of care.

Using three perspectives—an evolutionary, histori- cal approach to development; a descriptive, structural approach; and a sketch of the economic anatomy of the system of public psychiatry—this chapter o ers an intro- duction to the system of public psychiatry. e chapter describes how not only scienti c and professional principles have guided the evolution of the system but also, inevitably, how political and economic forces have shaped it as well. e net result is a de facto system with multiple sources of funding that has little coherence or logic. Focusing on the recovery of people with SMIs and addictions as a value helps to also maintain focus on the needs of this key target population as other political, economic, scienti c, and pro- fessional forces shape the system going forward. e bot- tom line is that the system must be monitored to keep an eye on the array of services o ered to assure they are reason- ably comprehensive, balanced, and evidence-based in order to meet the needs of people with SMIs and addictions—the essential target population of public psychiatry.

As mental health professionals work in the domain of public psychiatry and serve those seeking help, they learn about and operate in the service system, where they weave together plans of care to meet the needs of individuals.


is chapter is intended to help the advanced professional student get started. From state to state, county to county, and city to city, the system di ers, and professionals must develop their own understanding of their particular locale. It is the individualized, person-centered plan of care, devel- oped through an interdisciplinary clinical team that pro- vides a roadmap of care within each system. It is also a key professional task, while serving individuals, to try to com- pensate for de ciencies in the system. Outside the clinic, there is also an opportunity to advocate for missing ser- vices. e system faces many challenges over the next few years, including managing increased access, maintaining a focus on people with SMIs and addictions, implementing integrated health care, integrating a population perspective into practice, and maintaining a full spectrum of acute and long-term clinical, rehabilitative, and mental health services and supports.

Although it is possible to describe the service system of public psychiatry and characterize its status, it is important to appreciate that the system is not static. Indeed, it con- stantly evolves as new evidence, new policy initiatives, new professional standards, and new political and social events occur. Looking at the system as dynamic, the nal chapter of the textbook discusses the multiple factors shaping the system of public psychiatry at present.


1. President’s New Freedom Commission Report. Achieving the Promise: Transforming Mental Health Care in America. Rockville, MD: President’s New Freedom Commission on Mental Health; 2003.

2. Department of Health and Human Services. A Report of the Surgeon General. Rockville, MD: USDHHS, SAMHSA, CMS, NIH, NIMH; 1999.

3. Jacobs S. Inside Public Psychiatry. Shelton, CT: PMPH Press; 2011.

4. Foley HA, Sharfstein SS. Madness and Government: Who Cares for the Mentally Ill. Washington, DC: American Psychiatric Press; 1983.

5. Goldman H, Morrissey J, Ridgeley M, Frank R, Newman S, Kennedy C. Lessons from the program on chronic mental illness. Health A .

6. Grob G, Goldman H. e Dilemma of Federal Mental Health
Policy: Reform or Incremental Change. New Brunswick, NJ: Rutgers
University Press; 2007.

7. Mark TL, Levit KR, Buck JA, Co ey RM, Vandivort-Warren R.
Mental health treatment expeditures trends, 1986–2003. Psychiatr
Serv. 2007;58(8):1041–1048.

8. Frank R, Glied S. Better But Not Well: Mental Health Policy in the
United States since 1950. Baltimore, MD: Johns Hopkins University
Press; 2006.

9. Glied S, Frank R. Trends in the well-being of the mentally ill. Health
A . 2009;28:639–648.

10. Davidson L, Tondora J, O’Connell MJ, Kirk T, Rockholz P, Evans AC. Creating a recovery-oriented system of behavioral health care: mov- ing from concept to reality. Psychiatr Rehab J. 2007;31(1):23–31.

11. Mechanic D. Seizing opportunites under the A ordable Care Act for transforming the mental and behavioral health system. Health A . 2012;31:376–382.

12. Kirk T, Di Leo P, Rehmer P, Moy S. Case and care management can improve outcomes while reducing costs and service demand. Psychiatr Serv. 2013;64(5):491–493.

13. StefancicA,TsemberisS.Housing rstforlong-termshelterdwellers with psychiatric disabilities in a suburban county: a four-year study of housing access and retention. J Prim Prev. 2007;28(3–4):265–279.

14. Astrachan B. e pragmatics of health care delivery. Conn Med. 1974;37:1774–1779.

15. Moses H, Matheson D, Dorsey E, Benjamin P, Sado D, Yashimura S. e anatomy of health care in the United States. JAMA. 2013;310(18):1947–1964.

16. Kaiser Comission on Medicare and the Unisured. Mental Health Financing in the United States: A Primer. 2011. https://kaiserfami- lyfoundation. Accessed 10/22/15.

17. Substance Abuse and Mental Health Services Administration, National Expenditures for Mental Health Services and Substance Abuse Treatment, 1966-2009, HHS Publication No. SMA 13-4740, Rockville, Maryland, SAMHSA, 2013.

18. Substance Abuse and Mental Health Services Administration, State Level Spending on Mental Health Services and Substance Abuse Treatment, 1997-2005, Rockville, Maryland, Center for Mental Health Services and Center for Substance Abuse Treatment, SAMHSA, 2012.

19. Sowers W, Benacci R. LOCUS, Training Manual: Levels of Care Utilization System for Psychiatric and Addiction Services Adult Version 2000. CSPlocustrainingmanual.pdf. Published 2000. Accessed January 3, 2015.

20. Glover RW, Miller JE, Sadowski SR. Proceedings on the State Budget Crisis and the Behavioral Health Treatment Gap. Paper presented at: National Association of State Mental Health Program Directors meeting; March 22, 2014; Washington, DC.

21. Szabo L. e cost of not caring. USA Today. May 12, 2012. http:// health-system-crisis/7746535/. Accessed 8-24-15

22. Prinz S. Does trans-institutionalization explain explain the over- representation of people with serious mental illness in the criminal justice system? Comm Ment Health J. 2011;47:716–722.

23. Insel T. Translating scienti c opportunity into public health impact: a strategic plan for research on mental illness. Arch Gen Psychiatry. 2009;66:128–139.

24. Lieberman JA, Stroup TS, McEvoy JP, et al. E ectieness of antipsy- chotic drugs in patients with chronic schizophrenia. N Engl J Med. 2005;353(12):1209–1223.

25. Wang P, Ulbricht C, Schoenbaum M. Improving mental health treatments through comparative e ectiveness research. Health A . 2009;28(3):783–791.

26. Barkil-Oteo A. Collaborative care for depression in primary care: how psychiatry could “troubleshoot” current treatments and practices. Yale J Biol Med. 2013;86(2):139–146.

27. Kreyenbuhl J, Buchanan RW, Faith B, Dickerson FB, Dixon LB. e Schizophrenia Patient Outcomes Research Team 8. (PORT): updated treatment recommendations. 2009. Schizophr Bull. 2010;36:94–103.




Larry Davidson, Janis Tondora, Maria J. O’Connell, Chyrell Bellamy, Jean-Francois Pelletier, Paul DiLeo, and Patricia Rehmer


e central theme of this chapter is how recognition of the fact that many people recover from behavioral health conditions, and many others nd ways to live self-determined and meaningful lives in the face of pro- longed behavioral health conditions, has changed and will continue to change public psychiatric practice. Key points include:

• Serious mental illnesses are not necessarily life-long or permanently disabling conditions, which has been accepted as conventional wisdom since the era of institutionalization.

• People have gured out how to live full and meaningful lives in the community despite mental illnesses and/or addictions. Treatment has played a limited role in their e orts to reclaim their lives and has been most e ective when it builds on the foundation of a positive identity and sense of belonging.

• Recovery-oriented practice reverses the traditional order of “recover rst and return to the community a er”; instead, it establishes a meaningful life rst and, within that context, uses treatment as a tool to further the person’s recovery.

• Peer-delivered services can play e ective and important roles in assisting people to create and sustain meaningful lives of their choice.

• In the future, behavioral health services will be assessed based on the degree to which they enable people to live the lives they have reason to value.


As noted in Chapter 2, calls began as early as 1999, in the US Surgeon General’s Report on Mental Health, for all mental health services to become more consumer-oriented and to promote recovery. By the 2003 US Presidential New Freedom Commission, a new de nition of recovery—in contrast to the traditional medical notion of recovery that requires eliminating or overcoming an illness—was being heralded as “the process in which people are able to live, work, learn, and participate fully in their communities.”1 Since that time, the transformation to a recovery orienta- tion and to recovery-oriented systems of care2 has become

the overarching policy direction for publicly funded behavioral health services across the United States and abroad.3,4 How did this happen? Where did the concept of recovery as di erent from cure come from? And what implications does this concept have for transforming pub- lic psychiatric practice? ese are the questions we take up in this chapter.

We begin with a brief historical introduction to the con- cept of “being in recovery” or “personal recovery” (as dif- ferentiated from “recovering from” or “clinical recovery”5,6), and then we turn to its implications for practice. We will discuss some of these implications as they relate to o ering person-centered care, implementing peer support, and using


new tools to assess care quality and outcomes. Although these categories do not exhaust the many components of recovery-oriented practice, they do cover a majority of the territory that students, trainees, and new practitioners will likely encounter in their early days in public psychiatry ser- vice settings. Resources are included at the end of the chap- ter for readers who are interested in delving into any of these topics in more depth or detail.

As noted in the introductory chapter, being “recovery-oriented” is the h characteristic that we envision as embodied in optimal service delivery in pub- lic psychiatry. Here, we suggest that recovery-oriented practice cannot stand alone but instead requires the fol- lowing nine characteristics of optimal service delivery as well: it is (1) provided largely by interdisciplinary teams of professionals and specialists; (2) informed by an understanding of the assets and resources of the local community and the values, preferences, experiences, and needs of the population served; (3) systemic (o ered within a ROSC); (4) person-centered; (5) culturally competent; (6) community-based; (7) evidence-based; (8) competency-based (through training); and (9) driven by service user and family involvement as part of both quality improvement and all other levels of system, agency, and program operations.


Where did this new meaning for the term “recovery” come from in relation to mental illness and addiction, and how did it come to exert such in uence on public policy in the United States? We should not infer from the use of the term in federal policy documents (such as the Surgeon General’s and New Freedom Commission reports) that it was intro- duced or promoted initially by policy-makers themselves. Rather, the call for services to be reoriented to the pro- motion of recovery came about gradually, in response to increasingly visible and e ective lobbying e orts by the mental health consumer/survivor movement, which began to coalesce in the United States in the 1970s, and by the new recovery advocacy movement in addictions, which began in the 1990s.7

Mental health consumer/survivors (also called ex- patients, ex-inmates, “mad” people, and, most recently, service users) are people who describe themselves as hav- ing a history of receiving (or using) mental health ser- vices in the past and who, based on those (o en harmful) experiences, have taken up an advocacy role to change the nature of the services o ered and the ways in which such

services are provided. Although there have been such ex-patient advocates throughout the history of mental health care—most notably perhaps Dorothea Dix and Cli ord Beers—it was not until the 1970s that a political movement made up of large numbers of such individuals began to gain traction. Beginning at the grassroots level in urban areas on the West and East Coasts, by the time the Carter Commission on Mental Health got under way, there was an increasing number of mutual support/ self-help groups made up of articulate and e ective mental health consumers across the country. ese con- sumer leaders were included in the initiation and devel- opment of the Community Support Program (CSP) at the National Institute of Mental Health, which was the primary accomplishment of the Carter Administration’s e orts to improve mental health care. Two key compo- nents of the CSP model were that persons with serious mental illnesses (SMIs) would have access to mutual support/self-help groups in their local community and, perhaps more importantly, that consumer and family advocates would have “a seat at the table” in the develop- ment and governance of the community-based systems of care that were to be developed to serve them within each geographic catchment area.

As noted in Chapter 1, the Reagan Administration cut all new funding that had been allocated to develop such sys- tems of care, but a foundation for the Recovery Movement had been established nonetheless. By the 1980s, increasing numbers of persons with histories of involuntary con ne- ment and other negative experiences with mental health care were joining the consumer/survivor movement, devel- oping mutual support programs, and becoming outspo- ken role models for others. It was within this context that Patricia Deegan (a mental health consumer advocate who had gone on to receive a doctorate in clinical psychology) and William Anthony (a long-time leader in psychiat- ric rehabilitation who directed the Center for Psychiatric Rehabilitation at Boston University) rst began to talk and write about a new meaning for the term “recovery.”

Deegan’s 1988 paper, “Recovery: e Lived Experience of Rehabilitation,” was perhaps the rst to make the distinc- tion between having recovered from a mental illness and being in an ongoing process of recovering. In what became a highly in uential passage, she wrote that “Recovery refers to the lived or real life experience of people as they accept and overcome the challenge of the disability … they expe- rience themselves as recovering a new sense of self and of purpose within and beyond the limits of the disability.”8 Soon therea er, Anthony o ered his own in uential de ni- tion of recovery:


A deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and roles. It is a way of living a satisfying, hopeful, and contribut- ing life even with limitations caused by the illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic e ects of mental illness.9

Anthony went on to declare this new meaning of recov- ery as the “guiding vision of the mental health service sys- tem in the 1990s,” referring to the 1990s as “the decade of recovery.”

No doubt, this new vision of recovery appealed to large numbers of persons who had been diagnosed with SMIs not only because of the combination of Deegan’s eloquence and Anthony’s hopefulness, but also because of their own real-life experiences. At around the same time, an emerging body of longitudinal research was showing that outcomes for SMIs were much less predetermined, much more diverse than had previously been thought. Despite the lack of funding for community-based care and the myriad other di culties encountered during deinsti- tutionalization, studies beginning in the late 1960s were showing that, outside of hospital settings, many persons with SMIs were experiencing signi cant improvements in their conditions over time.

Ground-breaking studies by Strauss and Carpenter10–12 and Harding and colleagues13–15 in the United States, along with work by colleagues abroad,16 were consistently disprov- ing the long-held, mainstream view (attributed to Kraepelin, 190417) that schizophrenia was a life-long illness that inevi- tably led to progressive deterioration. Rather, they were nd- ing that up to 67% of their samples experienced signi cant improvements over time, with many recovering fully from the disorder. Among those who did not recover fully, there was a range of functioning found both across and within individuals.18 In other words, some people improved in some areas (e.g., social functioning) while not others (e.g., symp- toms), and the remaining 33% of the sample fell at many di erent points along a broad continuum of outcomes from progressive deterioration to clinical stability.

By the 1980s, these data led to a reconceptualization of outcome in schizophrenia and other SMIs, from one of a chronic course leading to inevitable decline to one of het- erogeneity in both course and outcome.19 In brief, a body of scienti c evidence not only allowed for but actively sup- ported an emerging vision of recovery as a process by which people led self-determined and meaningful lives either in the absence or in the ongoing presence of an SMI. Full recovery is possible, but even for those who do not recover

fully, who are not cured, it is still possible to “be in recov- ery,” to derive a sense of “personal recovery” in living one’s life despite or in the face of the lingering e ects of illness. What remained to be determined was how such a reconcep- tualization of SMI, and an analogous rede nition of recov- ery in addiction, would change practice.


As this vision of recovery took hold, mental health advo- cates joined forces with other disability rights advocates to develop and lobby for the 1990 passage of the Americans with Disabilities Act (ADA). Passage of the ADA may be considered a watershed event in ushering in the recovery movement because inclusion of mental illnesses and addic- tions as disabilities under the purview of the ADA reframes much of the legal and cultural context in which behavioral health practitioners now practice. If an SMI is a disability, then a person with an SMI, under the ADA, retains all of the rights and associated responsibilities of community membership as do other citizens. He or she is to be a orded access to a life in the community of his or her choice, as are other citizens, and, should accommodations be required to a ord such access, they are to be provided (as long as they are considered “reasonable”).

By “reasonable accommodations,” the ADA refers to such things as wheelchairs, wheelchair ramps, and handrails in bathrooms that are provided so that persons with mobil- ity impairments will be able to access public spaces as much as possible like everyone else. Although we are still in the learning phase as to what psychiatric accommodations may end up looking like, adoption of a disability model of men- tal illness and addiction has allowed advocates to insist that people not be cured of their mental illnesses or substance use rst before rejoining community life as full, contribut- ing members. Adoption of this model has dramatic and far- reaching implications for how behavioral health care needs to change to support people in rejoining their communities even while they may remain disabled by a mental illness or addiction.

One way to think about the nature of this change is to consider much long-stay hospital practice has changed over time in most places. People were admitted to the hos- pital because they were sick, they received treatment in the hospital that would make them better, and then they were discharged to the community when they were well. In the hospital, people adopted the “sick role,” which would absolve them of any responsibilities but also of any sense of


personal agency or autonomy. Under this form of practice, in the hospital, other people make decisions for you and do things to you because you are in no condition to do so for yourself. Although the adoption of the sick or patient role may be appropriate to acute illnesses and acute care, doing so undermines long-term recovery by ignoring those inter- nal resources the person needs to do battle with illness or, even worse, leading to their atrophy (along with brain cells). Yet, as many critics have pointed out, this hospital frame- work followed people with mental illness or addictions out of long-stay institutions into the community during deinsti- tutionalization and has, according to recovery proponents, permeated community-based services since. We still operate largely with a “be cured or recover rst and then take your life back a erward” perspective, even though we no longer practice primarily in hospitals. Changing this perspective has been a major focus of the recovery movement.

We should acknowledge at this point that there is a tremendous amount of diversity to be found under the rather broad tent of recovery when it comes to discerning its implications for practice. Advocates who identify as “ex- inmates,” “survivors,” or “mad” typically view the mental health system as beyond repair and also view the diagnosis of “mental illness” to be other than an illness per se (e.g., mental illness as the e ects of distress or trauma). Similarly, there are di ering views in the addiction treatment eld, with some advocates arguing for a narrow standard of com- plete abstinence as required by the 12-step fellowship and therefore showing little interest in transforming behavioral health care, preferring to argue for self-help options for per- sons experiencing di culties in their lives. Other advocates have entered into partnerships with behavioral health prac- titioners and system leaders to develop new practices that could be considered recovery-oriented and for which an evidence base could then be established. e next two sec- tions of this chapter will focus on describing a few of those developments, along with presenting data that have been collected thus far relative to each practice.

By way of introduction, though, it might be useful rst to list the principles for recovery-oriented care that resulted from a consensus development conference con- vened by the Substance Abuse and Mental Health Services Administration (SAMHSA) in 2010.20 ese principles were o ered to guide service system development for persons with either mental health and/or substance use conditions, in response to growing recognition of the high prevalence of co-occurring disorders and the need to integrate mental health and addictions services under one conceptual frame- work that will allow for integration at the person, program, and system levels.21 e de nition developed by SAMHSA

to span mental health and addiction states that recovery is “A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.”2 Based on this de nition, the following ten principles were established to guide the devel- opment of recovery-oriented practices:

• Recovery emerges from hope;

• Recovery is person-driven;

• Recovery occurs via many pathways;

• Recovery is holistic;

• Recovery is supported by peers and allies;

• Recovery is supported through relationship and social networks;

• Recovery is culturally based and in uenced;

• Recovery is supported by addressing trauma;

• Recovery involves individual, family, and community strengths and responsibility; and

• Recovery is based on respect.
ese principles suggest that, for persons with mental illnesses and/or addictions, they, their families, and their communities are responsible for the person’s recovery. e role of the practitioner is perhaps best framed as that of an expert consultant who has information, skills, educa- tion, treatments, and other interventions to o er in sup- port of the person’s and family’s own e orts at recovery. Each party, including the broader community, possesses strengths and resources that can be identi ed and built on in the recovery process, which can evolve in many dif- ferent ways for di erent people. People are supported in their recovery when they are respected and treated with dignity as whole human beings who are more than just their diagnosis or illness; when they are o ered hope; and when their cultural identity, values, a liations, and pref- erences are honored. Many persons with mental health and/or substance use disorders (SUDs) have histories of trauma, and, if le unaddressed, this history can impede recovery e orts. Finally, a main avenue for promoting recovery is through the person’s relationships with oth- ers, including but not limited to family. ese relation- ships need to o er the person a sense of being accepted and cared for as a worthwhile, unique individual who is, or has the potential to be, valued as a contributing mem- ber of society. In contrast to the hospital or detox/rehab- based model of “recover rst and have a life second,” the


model for recovery-oriented practice is “accept me as a whole person with a unique and important story rst, and then we can work together on nding and traveling together down those pathways that are most conducive to my recovery.”

Implicit in this last sentence, a substantive shi in our conceptualization of mental health and addiction care occurs when we move from the perspective of the practitio- ner and what treatments or other interventions he or she has to o er his or her clients or patients to the perspective of the person receiving or using the care and what he or she needs from others in order to pursue his or her own recovery. In the case of the new recovery advocacy movement in addic- tions, this has involved moving from an acute care model of disconnected episodes of practitioner-driven treatments to a “recovery management” model that supports the per- son’s own long-term e orts to pursue, enter into, and sus- tain recovery among a community of supportive family and peers.22 As with mental health care, services and supports for persons in active addiction seek to help the person estab- lish a solid sense of community membership as a founda- tion for pursuing recovery in the community, rather than focusing primarily on detoxi cation and the reduction of substance use and cravings, o en in institutional settings. Treatment is reconceptualized as a tool for the person to use in his or her everyday and ongoing life as opposed to some- thing to be completed following an acute episode. is shi is made operationally in the provision of person-centered care, to which we turn next.

Prior to doing so, though, it is important to point out a common misunderstanding of the terms “recovery,” “recovery-oriented practice,” and “psychiatric rehabilita- tion.” e eld of psychiatric rehabilitation predated the advent of the recovery movement and refers primarily to what psychiatric rehabilitation practitioners do in their practice, including skills training, remediation of functional de cits, and provision of community-based supports (see Chapter 4). Recovery, as pointed out by Deegan, refers to what a person with a mental illness (or addiction) is doing to manage his or her condition and to live the fullest and most meaningful life possible. It refers to the real-life or lived experiences of the person with the condition. Recovery- oriented practice refers to what behavioral health and other practitioners do to support people and their loved ones in their own e orts at recovery. Recovery-oriented practice may therefore include a number of psychiatric rehabilitative interventions, as well as other interventions that are clini- cal or supportive in nature, as long as they are o ered in a respectful, collaborative manner as part of a person-driven recovery plan.


Although the origins of person-centered care are to be found in the seminal work of Carl Rogers23 and the Independent Living Movement of persons with physical disabilities beginning in the early 1970s, the case for all of medicine, including psychiatry, to shi to this paradigm was made more recently in a 2001 Institute of Medicine (IOM) report entitled Crossing the Quality Chasm: A New Health System for the 21st Century. is report argued that the active involvement of patients in their own care and the tailoring of that care to meet their own individual needs were necessary measures for improving the safety, quality, and outcomes of all health care.24 is belief also permeates the design of the A ordable Care Act (ACA) passed in 2010 and currently under implementation across the United States.

As part of the ACA, practitioners are encouraged not only to o er person-centered care, but also to integrate all the services a person receives by ensuring that each person is provided with a person-centered health “home.” A key mechanism for coordinating care, especially for persons with multiple or complex conditions, is through develop- ment of a person-centered care plan, which we have de ned previously as “involving a collaborative process between the person and his or her service providers and support- ers that results in development and implementation of an action plan that will assist the person in achieving his or her unique, personal goals.”25

Within the context of behavioral health speci cally, we suggest that, for the plan to be considered “person-centered,” it needs to “(1) be oriented toward promoting recovery rather than only minimizing illness; (2) be based on the per- son’s own goals and aspirations; (3) articulate the person’s own role and the role of others, both paid and natural sup- ports, in assisting the person to achieve his or her own goals; (4) focus and build on the person’s capacities, strengths, and interests; (5) emphasize the use of natural community set- tings rather than segregated program settings; and (6) allow for uncertainty, setbacks, and disagreements as inevitable steps on the path to greater self-determination.”25

In previous publications, we identi ed the following ve guiding principles for ensuring that recovery-oriented care is provided in a person-centered fashion.26,27

1. Person-centered care identi es and builds on people’s own strengths and the resources and opportunities that exist in their community.

Person-centered care focuses on the restoration or continued support of the person living a meaningful


and gratifying life in the community of his or her choice. Disease, disability, and various forms of dysfunction are not ignored but are viewed instead as potential obstacles to the life the person wishes to lead. For this reason, practi- tioners rst need to get to know the person and what he or she is trying to do in life because this provides the context for treatment and other interventions. What the person is trying to do, where he or she is trying to do these things, what strengths and resources the person brings to these pur- suits, and who else will support him or her in doing so are all important dimensions to consider in the planning and provision of recovery-oriented care.

2. Person-centered care focuses on equipping and empowering people to play an active role in the self- management of their conditions.

Person-centered care is based on the premise that peo- ple are the primary agents in their own lives and will make their own decisions as to how they will (or will not) take care of themselves on an everyday basis. is remains true even in the lives of those who have been demoralized by an SMI and/or addiction and the discrimination associated with these conditions. For such individuals, an early step in person-centered care may be to help them view themselves as agents in their own lives who can learn how to exercise self-care. In this way, the focus in person-centered care shi s from what the practitioner needs to do to treat and manage the illness to what the individual needs to know and know how to do in order to take good care of him- or herself given the conditions that he or she has.

3. e planning and provision of person-centered care are collaborative processes in which persons and their natu- ral supports are encouraged and enabled to play active, substantive roles.

In parallel to the active role people play in their own self-care, person-centered care involves people playing an active role in collaborating with their practitioners in all decision-making processes. ese include not only making decisions about speci c treatments, perhaps using shared decision-making tools, but also decisions about who will be involved in care planning discussions and about the life goals on which the care to be provided is based. For indi- viduals who prefer to have others involved in their decision- making based on cultural or other preferences, practitioners are to honor these preferences because it would not be very “person-centered” to insist that people make their own decisions when their preference is to defer to the wisdom of family or elders.28

4. Person-centered care recognizes the “dignity of risk” and the “right to fail” that most people with most mental illnesses retain most of the time.

Person-centered care is also based on the premise that, in the absence of serious, imminent risk or grave disability, adults with mental illnesses and/or addictions retain the right to self-determination. is means that these adults, unless assigned conservators or guardians by a judge, retain the right to live the lives of their choosing. Acknowledging this right in person-centered care requires not only “allow- ing” people to set their own goals and make their own deci- sions (and therefore their own mistakes), but also actively encouraging them to do so. is does not absolve practitio- ners from their societal obligation to protect the person and community from harm, but it does limit that obligation to circumstances in which there is clear and compelling evi- dence of such a risk. In this respect, person-centered care is o ered within a framework of competent risk assessment and management, balanced by recognition of the fact that most persons with most mental illnesses pose no more of a risk to self or the community most of the time than most per- sons without mental illnesses do.29 e same cannot be said, however, for persons with addictions. Here, the argument is made that people are more likely to use and sustain pathways to recovery that they nd more consistent with their own values, preferences, and cultural identity and a liations.

5. e provision of person-centered care is based on a person-centered care plan that the person and his or her supports have played integral roles in creating in part- nership with his or her health care practitioners.

As noted earlier, the provision of person-centered care is based on a person-centered care plan. A person- centered care plan is a plan for how the person will be enabled to live a life he or she has reason to value,30 and it includes the services and supports he or she may need in order to do so, including those treatments required for reducing or overcoming symptoms and other barri- ersposedbymentalillnessoraddiction.Becausetheplan also is oriented toward promoting self-care, it includes the action steps the person will need to take on his or her own behalf, as well as those tasks family and friends have agreed to take on in support of the plan. Finally, it is important that the person and his or her natural support- ers play as signi cant a role in collaborating with practi- tioners in developing the plan as they are expected to play in implementing the plan.

In addition to these guiding principles, a number of characteristics of person-centered care planning have been


articulated and serve as the basis for a delity tool.31 ese characteristics pertain to details of the planning process, care plan document, and process of implementation and documentation to ensure that the process of developing and using the plan embodies the principles just described and illustrates how these principles translate concretely into actual practice.27 Key characteristics include conducting a strength-based assessment, eliciting and assisting people to articulate their own life goals, involving the person and his or her natural supports in the scheduling and conduct of the planning meeting, o ering the person a copy of his or her plan, identifying a range of professional and community- based supports and alternative interventions to support the person’s recovery from which he or she may make meaning- ful choices, identifying the steps the person and his or her natural supports will take in pursuit of the person’s goals, and using person- rst language—and avoiding professional jargon—in documenting the plan and progress made (or not made) in implementing the plan.

In terms of the accumulating evidence base supporting this approach to care, a recent review paints a consistent picture of positive e ects resulting from enabling persons to take on active roles in and to make decisions about their own care.32 First, o ering people choices in their care enhances their initial engagement and the likelihood that they will stay in care long enough to derive bene t from it.33–39 Second, once engaged, persons o ered person-centered care are more likely to adhere to prescribed medications,40–44 with both quantitative and qualitative studies showing an inverse relationship between perceived coercion and adherence.45,46

Finally, reductions in symptoms and improvements in functioning have been found in both psychiatric and medi- cal conditions as a result of emphasizing autonomy and a ording people more choices.47–52 Rates of rehospitaliza- tion and use of costly emergency and acute care services have been reduced,33,53–55 while improvements in other domains include patient satisfaction,49,56–60 residential stability,50,53,54 cost-e ectiveness,61 rates of job placement, length of job ten- ure and satisfaction with earnings,62–64 and quality of life.64–66


Peer support has become perhaps the most visible and rap- idly growing outgrowth of the mental health consumer/ survivor and new recovery advocacy movements to date. In its contemporary form, hiring people who have experi- enced their own mental illness and/or addiction and who have recovered or are “in” recovery to provide support to others began in the late 1980s in the United States. Early

e orts were a somewhat natural extension of the growth of self-help/mutual support groups around the country, as practitioners became aware of these community groups and their members and began to realize that some of the bene ts of these relationships could be brought into the behavioral health system. One strategy for doing so was to invite people who were doing well to come back and men- tor others who were not as far along in their own recoveries. Initially, these positions were created as volunteer opportu- nities, but, by the early 1990s, they had become paid posi- tions in which persons in recovery were beginning to play a variety of roles, from case management assistants and resi- dential sta to the new role of recovery educator.

What has happened since then has been nothing short of extraordinary. e number of peer support sta in the United States practicing both inside and outside of the formal behavioral health system currently numbers in the tens of thousands. e Veterans Administration alone has already employed more than 1,000 peer sta in its hospitals and medical centers. More than 30 states have used waiv- ers to secure Medicaid reimbursement for peer-delivered services, an international peer support network has been formed (with a listserv topping 3,000), and more than 3,000 practitioners of peer support have had input into a rst set of US practice guidelines for their rapidly emerging profession (with an ethics statement and set of competencies soon to follow), with similar advances occurring in other countries (e.g., Canada, Scotland). And although mental health prac- titioners may have initially opened the doors of the system to invite peers in, it has been the peers who have generated the energy, excitement, and e ects that are coming to be associ- ated with this relatively new form of service delivery.

We refer to peer support as “relatively new” because it actually has a much longer and more distinguished lineage in psychiatry than most readers might realize. In fact, one of the rst references found to hiring former patients to help care for current patients appears in Pinel’s 1801 Treatise on Insanity (English translation, 1806). Pinel describes the “simple” yet central strategy employed by Jean Baptiste Pussin, governor of the Bicetre Hospital in Paris when he arrived there to be Chief Physician in the 1790s: “His servants were generally chosen from among the convales- cents.”67 Pinel knew this prior to his arrival at the Bicetre because he had sent Pussin a letter asking him to describe his strategies for managing the hospital and what he had found helpful in caring for his patients. In what is most likely the rst documentation of this practice, Pussin replied in his let- ter that: “As much as possible, all servants are chosen from the category of mental patients.”68 Once at the Bicetre, Pinel came to see the transformative e ect this practice had on


the hospital rst-hand and soon came to describe Pussin’s management practices as “moral treatment.”69

In the history of psychiatry, there are other examples of rediscoveries of the power of peer support, such as Harry Stack Sullivan’s practice of hiring his own recovered patients to sta his inpatient unit for young men experiencing psy- chosis in Baltimore in the 1920s. One certainly could argue that a key therapeutic agent in the therapeutic community model that dominated inpatient psychiatry in the 1950s and ‘60s was the role of recovering patients, even though in this case they were not paid for their work because their participation in the therapeutic milieu was considered part of their own treatment. e addiction eld has been stimu- lated and populated by various mutual support approaches throughout its history, with the most prominent contem- porary example being Alcoholics Anonymous and other 12-step derivatives. Similarly, one can look outside of psy- chiatry to many other branches of medicine to see the role that recovered or recovering peers can play in supporting people who are struggling, with a prominent example cur- rently being the growing population of cancer survivors, many of whom now choose to run peer support groups or outreach to persons newly diagnosed. e point of men- tioning these earlier and concurrent forms of peer support is simply to establish that the idea of having a person in recov- ery from a health condition play a useful role in supporting others with the same or similar condition is well-accepted in the general community. Even though this also may have been true in previous decades in psychiatry as well, when peer support was rst reintroduced into mental health set- tings in the 1990s it was considered by many to be an irre- sponsible, unethical, and potentially harmful practice.

We note the reception that peer support initially received in the mental health system because the form of discrimination it represents continues to challenge and undermine the e ectiveness of peer support being o ered in many settings across the country. e most formidable obstacles to the successful hiring and deployment of peer sta in mental health organizations are not the conditions from which people are recovering, but rather the cultures of the agencies themselves and the discriminatory attitudes and behaviors of (some) non-peer sta . Underlying this form of discrimination is the deeply held belief that once a person has a mental illness or addiction, he or she will have it for the remainder of his or her life and will be permanently compromised in his or her ability to function as a result. e very presence of peer support sta in mental health set- tings challenges this long-standing, entrenched belief. And it was, in part, for this reason (i.e., to challenge and disprove such beliefs) that peer sta were initially introduced.70

Since their introduction, though, peer sta have quickly shown that there are many more bene ts to their employ- ment than the transformative e ects they have on orga- nizational culture. Early studies were primarily feasibility studies, showing that it was in fact possible to train and hire persons in recovery with histories of SMIs or addictions to provide behavioral health services. In most of these studies, however, the peers had been hired to provide conventional services, such as functioning as case management assistants or residential sta . In these roles, peer sta were found to function equally as well as non-peer sta , with no di er- ences found in outcomes or other variables.71

e only positive di erence for peer sta functioning in conventional roles was found in one study of outreach and engagement to persons who would have been eligible for mandated outpatient treatment in a state that did not yet have outpatient commitment. To be eligible, partici- pants had to have an SMI, have shown a positive response to acute care during a previous hospitalization, have a pattern of refusing outpatient services once discharged, and have a history of violence or be at risk for violence. Participants were randomly assigned to either an outreach team that had hired peer sta or an outreach team that had not hired peer sta . Participants who were assigned to peer outreach sta became engaged in treatment more quickly and reported having a better relationship with sta than those assigned to non-peer sta . In this particular study, no adverse events were reported for participants in either study condition over the 2-year duration of the project.72

Although some proponents of peer support found these overall results disappointing, it soon became evident that many people hired into peer sta roles were not in fact trained or hired to provide peer support per se. ey were hired to function as case managers, as residential or employ- ment support sta , or as generic aides, with little empha- sis (if any) on using their own life experiences of illness and recovery to inform their work. In fact, some peer sta report being told that they could not disclose any informa- tion about their own recovery to their clients because this would violate professional “boundaries.” Such misunder- standings of the role of peer sta in providing peer support unfortunately continue to permeate the eld.73

More recent studies have begun to focus on the unique strengths and contributions that peer sta can bring to the provision of peer support—in contrast to conventional behavioral health services—and have begun to produce consistently positive ndings. In the role of peer sup- porter, people with histories of SMIs and/or addictions use their personal experiences of illness and recovery— along with relevant training and supervision—to facilitate,


guide, and mentor another person’s recovery journey by instilling hope, role modeling recovery, and supporting people in their own e orts to reclaim meaningful and self- determined lives in the communities of their choice.74 e numerous ways in which peers perform these functions as a rapidly growing part of the behavioral health work- force are further described in Chapter 4 on community supports.

e most robust and tangible research nding thus far related to the deployment of peer support sta in this uniquely “peer” capacity has been reductions in the rate and length of stay of costly readmissions for persons with SMIs and/or addictions leaving hospitals. Evaluations of programs in New York and Tennessee, for example, dem- onstrated reductions of 72% and 73% in rate of rehospi- talization and days spent in hospital, respectively.75 Our own study in Connecticut found a 42% reduction in read- missions and 48% reduction in days spent in hospital by persons with histories of multiple readmissions who were o ered peer mentors.76 A 2013 review commissioned by the National Health Service in England, entitled “Peer Support in Mental Health Care: Is It Good Value for the Money?” calculated that, on average, every British pound (£) spent on peer support resulted in a savings of £4.75 due to reduc- tions in hospital use.77

Finally, peer support has been shown to increase hope, empowerment, well-being, and quality of life and reduce substance use and depression among persons with mental illnesses and/or SUDs with histories of multiple hospital- izations and criminal justice involvement.74,78,79 Peer sup- port has also been shown to increase the involvement of persons with mental illnesses and/or addictions in their own care. A recent study conducted within the VA sys- tem, for example, found that veterans who were randomly assigned to care teams that included peer specialists became signi cantly more active and interested in taking care of themselves.80

As health care reform e orts focus on improving the quality of care and on promoting self-management, espe- cially among persons with long-term conditions, there will likely be heightened interest in building on this ability peers have to motivate persons with mental illnesses and/ or addictions and teach them self-care skills as members of interdisciplinary health home teams. Peers may also be particularly well suited to function as health navigators, and several studies are currently examining the various physical and behavioral health outcomes of peers functioning in this way as wellness coaches. Preliminary ndings suggest that the use of peers may enhance the timely access of persons with mental illnesses to primary care and specialty medical

services and may improve their physical and behavioral health, thus addressing their current disparity in life span while at the same time potentially reducing their overall Medicaid costs.74,78,81

Recent developments in peer-delivered supports have been somewhat di erent in the addiction eld. Here, there is a long history of substance use services being provided by persons who have their own personal history of recovery from addiction, and Alcoholics Anonymous and its many 12-step derivatives have long been seen as important mutual support complements to professionally provided treatment. In this case, new advances have been made in training and deploying peers—which here means persons in recovery from an addiction—to o er an array of what are described as “recovery support services.”2,82

e primary aims of recovery support services are to assist persons with SUDs to (1) establish and maintain environments supportive of recovery; (2) remove personal and environmental obstacles to recovery; (3) enhance link- age to, identi cation with, and participation in local com- munities of recovery, and (4) increase the hope, inspiration, motivation, con dence, e cacy, social connections, and skills needed to initiate and sustain the di cult and pro- longed work of recovery. ese services are far more likely to be delivered in the person’s natural environment than in clinical settings and, nested within the person’s social net- work, o en involve a larger cluster of family and commu- nity relationships.

In contrast to the acute care model, the recovery management model emphasizes a sustained continuum of pre-recovery (and pre-treatment), recovery initiation, and recovery maintenance supports. Recovery manage- ment models also include sustained recovery monitoring (including recovery checkups), stage-appropriate recov- ery education, active linkage to indigenous communities of recovery, and early reintervention.83–85 Finally, recovery support services may be provided by paid or volunteer sta and may be delivered by treatment agencies, local community providers (church, school, labor union), or grassroots and peer-run recovery advocacy or recovery support organizations.82

Examples of recovery support services include assertive outreach and engagement, case management (adapted from mental health), recovery coaching or mentoring (provided by peers), and other strategies and interventions that assist people in gaining the resources and skills needed to initi- ate and sustain recovery, such as transportation, child care, sober housing, social support, and community-based sup- ports to enable people to return to school, obtain and main- tain employment, and parent e ectively. Although in the


past such supports might have been considered to enable continued substance use (i.e., keep people from “hitting bottom”), in the new recovery advocacy movement they are seen as enabling engagement in care and ensuring that people make e ective and sustained use of the treatment resources available. Initial research con rms these func- tions, as well as suggests that the use of recovery support services can reduce acute care costs, increase “connect-to- care” rates following detox and residential treatment, and enhance the e ectiveness of treatments in reducing sub- stance use and maintaining abstinence over time.82,86 is use of peer-delivered interventions—as well as many other aspects of the growing peer support profession—appear to o er fruitful directions for innovation and future research.


In terms of new evaluation tools, governments need to rely on evidence and accurate measurements to justify the allocation of public funds for the development and implementation of new approaches regardless of their appealing, innovative, or progressive nature or outlook. Systematic measurement of impact has thus been high- lighted as a means of improving the evidence base and legitimacy of recovery as a recognized best practice.87 In terms of what is meant by recovery and how to measure it, though, two broad perspectives have generated quite di erent kinds of data. e rst perspective focuses on the dimensions of clinical recovery measured objectively through outcome studies and expressed as approximations to cure. When clinical recovery is understood as an out- come, it can be assessed by an observer with a focus on symptom reduction and the e ectiveness of treatments administered by behavioral health services. e other per- spective of “personal recovery,” in contrast, takes the form of subjective and self-evaluated accounts of how an indi- vidual has learned to accommodate living with an illness.88 As discussed previously, the personal recovery perspective is commonly understood as a process, one that can best be judged by the individual service user, with or without involving symptom reduction or referring to the actions of mental health services.6

Clinical recovery and personal recovery are di erent, and Bellack89 has referred to scienti c versus consumer models of recovery to distinguish between these perspectives. ese perspectives are not necessarily mutually exclusive, but they

do come from very di erent backgrounds, with the con- sumer model being associated with the consumer/survivor movement much more than with the scienti c or clinical communities. A plethora of measures already exist to assess clinical recovery from an observer point of view and in terms of speci c symptom reductions. ese will not be dis- cussed here. Instead, we wish to highlight the importance of person-identi ed and person-rated outcomes and how new tools have been systematically and rigorously developed to reliably assess personal recovery and the recovery orienta- tion of services. ese methods and tool are recognized as being no less scienti c than measures of clinical recovery. In that respect, we are grateful to draw on the work done by the Australian Mental Health Outcomes and Classi cation Network.

In 2010, Burgess, Pirkins, Coombs, and Rosen pro- posed a systematic review of existing recovery measures. eir identi cation of potential instruments drew on a search of Medline and PsycInfo that explicitly considered instruments designed to either measure individuals’ recov- ery or instruments designed to assess the recovery orien- tation of services. eir search yielded 33 instruments, of which 22 were designed to measure individuals’ recovery, and 11 were designed to assess the recovery orientation of services (or providers). e researchers were look- ing for scienti cally scrutinized instruments with sound psychometric properties (e.g., internal consistency, valid- ity, reliability). ey further applied exclusion criteria to assess whether given instruments might be candidates for measuring recovery in Australian public-sector men- tal health services from a consumer perspective, includ- ing being acceptable to consumers. Assessing these 33 instruments against these supplementary criteria resulted in eight instruments (seven emanating from the United Sates): four for individuals’ recovery (Table 3.1) and four for recovery orientation of services (Table 3.2). A more recent review that focused only on measures of personal recovery by Sklar and colleagues90 assessed the psychomet- ric properties, ease of administration, and degree of ser- vice user involvement in the development of each of these measures. e interested reader is referred to this review for details.

It is useful to note that the degree of service user involvement is considered especially crucial in assessing both personal recovery and the recovery orientation of services, programs, and agencies. Personal recovery, as we have de ned it, is subjective in nature and thus based in the service user’s own perspective. For this reason, service




Recovery Assessment Scale (RAS)

Illness Management and Recovery (IMR) Scales

Stages of Recovery Instrument (STORI)

Recovery Process Inventory (RPI)

5 • • • • •


Personal con dence and hope Willingness to ask for help Goal and success orientation Reliance on others
No domination by symptoms


Original version: • 41 items Short version:
• 24 items

Both client and clinician versions: • 15 items

• 50 items

• 22 items


Both versions:
• 5-point Likert Scale • Provider interview
• Consumer self-report

Both versions:
• 5-point Likert scale

• 6-point Likert scale
• Consumer self-report

• 5-point Likert scale • Provider interview


Corrigan, Gi ort, Rashid, Leary, & Okeke, 199993

Mueser, Gingerich, Salyers, McGuire, Reyes, & Cunningham, 200494

Andresen, Caputi, & Oades, 200695

Jerrell, Cousins, & Roberts, 200696

Does not purport to measure cohesive domains but instead to assess a variety of aspects of illness management and recovery

Five stages of recovery: • Moratorium
• Awareness
• Preparation

• Rebuilding • Growth

Six domains:
• Anguish
• Connectedness to others • Con dence/purpose
• Others care/help
• Living situation
• Hopeful/cares for self

Adapted from Burgess, Pirkins, Coombs, & Rosen, 2010.92

users have the only direct access to the body of lived experi- ence and expertise needed to conceptualize and measure this domain. As a result, they must be represented in any attempt to assess personal recovery, not only as partici- pants (obviously) but also as members of the research team as well.

As for measuring recovery orientation, some of the tools just described have already been incorporated into practice and program evaluation e orts, with the Recovery Self-Assessment, for example, having been used by more than 40 states and a dozen other countries to determine the recovery-orientation of existing or newly developed programs. eir use in more rigorous research, however, is just beginning and will likely increase signi cantly over the next decade. A key challenge facing all stakeholders— from practitioners, agency directors, and system leaders to clients, families, and researchers—is that, thus far, recov- ery has been implemented more in rhetoric than in actual practice. Perhaps it is for this reason that so many di erent tools have been developed to assess the recovery orientation of services even before we have established a consensus on what recovery-oriented care looks like in actual practice. In the development of an evidence-base for recovery-oriented

practice, it will be important to ensure that what is being evaluated for its e ectiveness is recovery-oriented in more than name alone. And, as has been implied in this chapter, the people who will be in the best position to determine this will be those using the services being o ered, along with their loved ones. For this reason, recovery proponents argue—if not insist—that service users also be members of research teams that evaluate recovery-oriented practices. is is currently a central focus of the growing movement in “service user-involved” research.91


As one example of the challenge in determining the nature of recovery-oriented practice, readers of this volume will undoubtedly hear practitioners use some recovery-oriented language in their clinical sites. Unfortunately, referring to someone as “a person with schizophrenia” or even “a person in recovery,” as opposed to “a schizophrenic,” is not all there is to adopting a recovery orientation. A basic sense of respect for the person is certainly important and provides an essential foundation for any other changes to be made in professional




Recovery Oriented Systems Indicators Measure (ROSI)


Consumer Self-Report Survey:
• Person-centered decision-making

and choice
• Invalidated personhood
• Self-care and wellness
• Basic life resources
• Meaningful activities and roles
• Peer advocacy
• Sta treatment and knowledge
• Access
Administrative Data Pro le:
• Peer support
• Choice
• Sta ng ratios
• System culture and orientation
• Consumer inclusion in governance • Coercion

Five domains:
• Life goals
• Involvement
• Diversity of treatment options • Choice

• Individually-tailored services

Eight domains:
• Meeting basic needs
• Comprehensive services
• Customization and choice
• Consumer involvement/participation • Network supports/community

• Strengths-based approach • Client source of control/

self-determination • Recovery focus

Five domains:
• Collaboration
• Participation and acceptance
• Self-determination and peer support • Quality improvement
• Development


Adult Consumer Self-Report Survey:
• 41 items Administrative Data Pro le:

• 23 items

Four versions of the same sur-
vey designed to elicit the views of consumers, family members and care, providers and agency directors Each version:


Combination of response formats:
• Closed-ended

• Likert scales
• Open-ended questions


Dumont, Ridgway, Onken, Dornan, & Ralph, 200597

Recovery Self- Assessment (RSA)

Recovery-Oriented Practices Index (ROPI)

Recovery Promotion Fidelity Scale (RPFS)

Each version:

O’Connell, Tondora,
Croog, Evans, & Davidson, 200598

Mancini & Finnerty, 200599

Armstrong & Ste en, 2009100

Adapted from Burgess, Pirkins, Coombs, & Rosen, 2010.92

practice. But our eld has espoused such respect for per- sonhood and even the need for our practice to be “person- centered” at least since the time of Pinel—if not, some would argue, all the way back to Hippocrates. Now we are being challengedonceagainto ndwaystoembodytheseprinciples in ways that are hopeful, strength-based, culturally relevant,

and based on the democratic values of self-determination and social inclusion. We anticipate that the coming generation of practitioners will see a plethora of innovative and idealistic e orts to establish multiple new pathways to recovery both insideandoutsideoftheformalbehavioralhealthsystem.We invite you, the reader, to join in.

• •

36 items


5-point Likert scale

20 items •

• Interviews with con-
sumers, family mem- bers or carers, service managers and service providers

• Document review

12 items •

5-point Likert scale (with some items attracting bonus points)

5-point Likert scale

• Survey which draws on the views of consum- ers, service managers/ administrators, provid- ers and family members or carers


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44. Williams GC, Rodin GC, Ryan RM, Grolnick WS, Deci EL. Autonomous regulation and long-term medication adherence in adult outpatients. Health Psychol. 1998;17(3):269–276.

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46. Roe D, Goldblatt H, Baloush-Klienman V, Swarbrick P, Davidson L. Why and how do people with a serious mental illness decide to stop taking their medication: exploring the subjective pro- cess of making and activating a choice. Psychiatr Rehabil J. 2009;33(1):38–46.

47. Green eld S, Kaplan S, Ware JE. Expanding patient involve- ment in care: e ects on patient outcomes. Ann Intern Med. 1985;102(4):520–528.

48. Greenwood RM, Schaefer-McDaniel NJ, Winkel G, Tsemberis SJ. Decreasing psychiatric symptoms by increasing choice in services for adults with histories of homelessness. Am J Community Psychol. 2005;36(3/4):223–238.

49. Langer E, Rodin J. e e ects of choice and enhanced personal responsibility for the aged: a eld experiment in an institutional set- ting. J Pers Soc Psychol. 1976;34(2):191–198.

50. Srebnik D, Livingston J, Gordon L, King D. Housing choice and community success for individuals with serious and persistent men- tal illness. Community Ment Health J. 1995;31(2):139–152.

51. Stewart M, Brown JB, Donner A, et al. e impact of patient- centered care on outcomes. J Fam Pract. 2000;49(9):796–804.

52. Williams GC, McGregor HA, Zeldman A, Freedman ZR, Deci EL. Testing a self-determination theory process model for promoting glycemic control through diabetes self-management. Health Psychol. 2004;23(1):58.

53. Chipper eld S, Aubry T. e supportive housing program in Winnipeg. Psychiatr Rehabil J. 1990;13(4):91–94.

54. Gulcur L, Stefancic A, Shinn M, Tsemberis S, Fischer S. Housing, hospitalization, and cost outcomes for homeless individuals with psychiatric disabilities participating in continuum of care and housing rst programmes. J Community Appl Soc Psychol. 2003;13(2):171–186.

55. Loh A, Leonhart R, Wills CE, Simon D, Härter M. e impact of patient participation on adherence and clinical outcome in primary care of depression. Patient Educ Couns. 2007;65(1):69–78.

56. Carlson BL, Foster L, Dale S, Brown R. E ect of cash and counseling on personal care and well-being. Health Serv Res. 2007;42(1):467–487.

57. Gattellari M, Butow PN, Tattersall MN. Sharing decisions in cancer
care. Soc Sci Med. 2001;52(12):1865–1878.

58. Ullman R, Hill JW, Scheye EC, Spoeri, RK. Satisfaction and
choice: a view from the plans. Health A . 1997;16(3):209–217.

59. Loh A, Simon D, Wills CE, Kriston L, Niebling W, Härter M. e e ects of a shared decision making in primary care of depres- sion: a cluster-randomized control trial. Patient Educ Couns.

60. Malm U, Ivarsson BB, Allebeck PP, Falloon IH. Integrated care
in schizophrenia: a 2-year randomized controlled study of two community-based treatment programs. Acta Psychiatr Scandinav. 2003;107(6):415–423.

61. O’Connell MJ, Kasprow W, Rosenheck R. Direct placement versus multistage models of supported housing in a population of veterans who are homeless. Psychol Serv. 2009;6(3):190–201.

62. Becker GR, Drake RE, Farabaugh A, Bond GR. Job preferences among people with severe psychiatric disorders in supported employ- ment programs. Psychiatr Serv. 1996;47(11):1223–1226.

63. Drake RE, Becker DR, Clark RE, Mueser KT. Research on the indi- vidual placement and support model of supported employment. Psychiatr Q. 1999;70(4):289–301.

64. Wehmeyer M, Schwartz M. Self-determination and positive adult outcomes: a follow-up study of youth with mental retardation or learning disabilities. Except Child. 1997;63(2):245–255.

65. O’Connell M, Rosenheck R, Kasprow W, Frisman L. An exami- nation of ful lled housing preferences and quality of life among homeless persons with mental illness and/or substance use disor- ders. J Behav Health Serv Res. 2006;33(3):354–365.

66. Swanson JW, Swartz MS, Elbogen EB, Wagner HR, Burns BJ. E ects of involuntary outpatient commitment on subjective

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prosumers into clinical settings. In: Mowbray CT, Moxley DP, Jasper CA, Howell LL, eds. Consumers as Providers in Psychiatric Rehabilitation. Columbia, MD: International Association for Psychosocial Rehabilitation Services; 1997:437–455.

71. Davidson L, Chinman M, Sells D, Rowe M. Peer support among adults with serious mental illness: a report from the eld. Schizophr Bull. 2006;32(3):443–450.

72. Sells D, Davidson L, Jewell C, Falzer P, Rowe M. e treat- ment relationship in peer-based and regular case management services for clients with severe mental illness. Psychiatr Serv. 2006;57(8):1179–1184.

73. Davidson L. Peer support: coming of age or miles to go before we sleep? J Behav Health Serv Res. 2013;96–99. doi: 10.1007/ s11414-013-9379-2.

74. Davidson L, Bellamy C, Guy K, Miller R. Peer support among per- sons with severe mental illnesses: a review of evidence and experi- ence. World Psychiatry. 2012;11(2):123–128.

75. New York Association for Psychiatric Rehabilitation Services. New York State Peer Services Fact Sheet. Albany: New York Association for Psychiatric Rehabilitation Services; 2012. http:// Session11_PS_FactSheet.pdf. Accessed February 1, 2013.

76. Sledge WH, Lawless M, Sells D, Wieland M, O’Connell M, Davidson L. E ectiveness of peer support in reducing readmissions among people with multiple psychiatric hospitalizations. Psychiatr Serv. 2011;62(5):541–544.

77. Trachtenberg M, Parsonage M, Shepard G, Boardman J. Peer Support in Mental Health Care: Is it Good Value for the Money? London: Centre for Mental Health; 2013.

78. Chinman M, George P, Doughtery RH, et al. Peer support services for individuals with serious mental illnesses: assessing the evidence. Psychiatr Serv. 2014;65(4):429–441.

79. Repper J, Carter T. A review of the literature on peer support in mental health services. J Ment Health. 2011;20(4):392–411.

80. Chinman M, Oberman RS, Hanusa BH, et al. A cluster randomized trial of adding peer specialists to intensive case management teams in the Veterans Health Administration. J Behav Health Serv Res. 2013;42(1):109–121.

81. Druss BG, Zhao L, von Esenwein SA, et al. e Health and Recovery Peer (HARP) program: a peer-led intervention to improve medical self-management for persons with serious mental illness. Schizophr Res. 2010;118(1):264–270.

82. Davidson L, White W, Sells D, Schmutte T, O’Connell M, Bellamy C, et al. Enabling or engaging? The role of recov- ery support services in addiction recovery. Alcohol Treat Q. 2010;28(4):391–416.

83. Dennis ML, Scott CK, Funk R. An experimental evalua- tion of recovery management checkups (RMC) for people with chronic substance use disorders. Eval Program Plann. 2003;26(3):339–352.

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89. Bellack, A. Scienti c and consumer models of recovery in schizo- phrenia: concordance, contrasts, and implications. Schizophr Bull. 2006;32(3):432–442.

90. Sklar M, Groessl EJ, O’Connell MJ, Davidson L, Aarons GA. Instruments for measuring mental health recovery: a systematic review. Clin Psychol Rev. 2013;33(8):1082–1095. doi: 10.1016/ j.cpr.2013.08.002.

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95. Andresen R, Caputi P, Oades L. Stages of recovery instru- ment: development of a measure of recovery from serious mental illness. Austral New Zeal J Psychiatry. 2006;40(11–12):972–980.

96. Jerrell J, Cousins V, Roberts K. Psychometrics of the Recovery Process Inventory. J Behav Health Serv Res. 2006;33(4):464–473.

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omas H. Styron, Janis L. Tondora, Rebecca A. Miller, Marcia G. Hunt, Laurie L. Harkness, Joy S. Kaufman, Morris D. Bell, and Allison N. Ponce


e move away from living in institutions to a life in the community for people with serious mental illnesses (SMI) and co-occurring disorders characterizes mental health care in the United States in the last half of the twentieth century. Before this period, much of treatment and rehabilitation for individuals with SMI and co-occurring disorders took place during long-term hospital stays and was provided—to the extent it was provided at all—within those walls. Since the 1960s, and in the past two decades in particular, a vari- ety of community supports and strategies for inclusion have emerged to assist individuals with SMI and co-occurring disorders in developing and sustaining lives not in the hos- pital but in the community (see Chapter 3 for a broader historical context).

e crucial importance of community supports and related strategies for community inclusion for individu- als with SMI and co-occurring disorders served as a focal point of the president’s 2003 New Freedom Commission.1 In 2004, the Substance Abuse and Mental Health Services Administration (SAMHSA) assembled a panel of consum- ers, families, and professionals who agreed that “recovery is a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential.”2 Subsequently, the SAMHSA3 delin- eated four major dimensions that support a life in recov- ery: Health—overcoming or managing one’s disease(s) as well as living in a physically and emotionally healthy way; Home—a stable and safe place to live; Purpose—meaningful daily activities, such as work, school, creative endeavors; and Community—relationships and social networks that provide support, friendship, love and hope. is chapter provides an overview of evidence-based supports and strat- egies for community inclusion. ese include housing,

employment, education, peer support, and psychosocial rehabilitation (PSR). Professionals in public psychiatry are encouraged to understand and employ these in their e orts to assist individuals with SMI and co-occurring disorders establish and maintain meaningful lives in communities of their choice.


In the wake of deinstitutionalization, supported housing was developed to provide opportunities for people with psychiatric disabilities to live in the community rather than in hospitals, jail, or on the streets.4 Although many people with SMI and co-occurring disorders live self-su ciently and independently in their communities of choice with- out supported housing, for others, housing supports are central to recovery. Multiple factors may lead to the desire or need for supported living arrangements. Poverty is a signi cant factor because low income a ects most people who live with SMI and co-occurring disorders,5 and the modest income that many people in recovery receive cre- ates signi cant problems in obtaining suitable housing,6 including increased risk for repeated or chronic homeless- ness.7 Personal choice is another important element in determining the best living situation for someone, although these preferences are sometimes at odds with the desires of clinicians and family members, with people sometimes pre- ferring to live alone and supporters sometimes suggesting congregate options like group homes.8

A range of housing and residential options are avail- able for individuals with SMI and co-occurring disorders, both for those who experience homelessness and those with housing. These can be in congregate or scattered- site locations and can vary in type from custodial care settings to permanent supportive housing arrangements.


Congregate living situations are those in which several people who have mental illness reside together in one loca- tion. ese settings may include the structure of a group home or nursing home, or they might be apartment build- ings where case management is provided to residents who maintain their own leases and units.

Scattered-site living arrangements are those in which people live in apartments located throughout the commu- nity, and these sites are not speci cally identi ed as units for people with disabilities. is model is employed as a means of promoting community inclusion and to increase oppor- tunities for interaction with people outside of the mental health system. ose living in scattered-site locations may still take advantage of services such as clinical care and case management, which are generally based o -site. Tsemberis and colleagues9 summarize several studies that indicate both advantages and disadvantages for congregate and scattered- site models, and they note the need for further research in this area.

In addition to the distinction between congregate and scattered-site models, which represent approaches to hous- ing programs, there are several types of residential and housing options that exist within these approaches. ese generally include custodial or residential care, housing con- tinuum or housing array, and permanent supportive hous- ing. ese options vary in terms of the level of support o ered to residents, the amount of independence exercised, and the permanency of the arrangement.

Custodial or residential care settings are those in which individuals receive a signi cant level of support from care- giver sta . ese programs are o en called “rest homes” or board-and-care facilities. ese settings, which usually operate as for-pro t businesses, are not generally designed to teach people independent living skills or facilitate reha- bilitation and thus o en serve as long-term placements.

Housing continuum and housing array programs are usually transitional in nature and vary in terms of how much support is o ered to residents. An assumption in these models is that rehabilitation can occur in the resi- dential setting. Traditional housing continuum models, which originated in the era of deinstitutionalization,8 generally employ a stepwise approach: as a person moves toward higher levels of independence, he or she will move to successively less supportive settings, with the ultimate goal of helping a person achieve independent housing. In contrast to the continuum model, the housing array model is more exible and does not prescribe any particular order in which residents should access di erent levels of care or require that they transition at any particular junc- ture. Both continuum and array programs usually require

engagement in clinical services and sobriety, and they range in intensity from group homes o ering around-the- clock sta ng to apartment programs that are sta ed for portions of the day and allow residents to experience more opportunity to develop independent living skills.

Permanent supportive housing (PSH) is an evidence- based practice10 that provides permanent housing to indi- viduals with SMI and co-occurring disorders and o ers treatment and other supportive services that are individu- ally tailored and may be intensive. According to Tsemberis and colleagues,9 the goal of PSH is “to improve social inte- gration and quality of life of people with psychiatric dis- abilities, to reduce the problems people have in achieving stable housing, and to increase the potential for successful recovery from psychiatric disability.” e housing is a ord- able or subsidized and can be either congregate or scattered- site. Individuals in PSH have a lease or sublease in their own names and enjoy the full rights of tenancy. eir leases have no requirements that are not expected of tenants who do not have SMI and co-occurring disorders (such as sobriety), and they cannot lose housing for failure to participate in services. Tenants are o ered a range of exible services that may vary in intensity over time, based on the individual’s needs and preferences.

An extensive literature base summarized by the SAMHSA11 demonstrates that PSH is e ective for indi- viduals with SMI and co-occurring disorders. One particu- larly well-cited study conducted in conjunction with the Corporation for Supportive Housing demonstrated reduc- tions in shelter use, number of hospitalizations, and length of hospitalizations and incarcerations among nearly 5,000 homeless individuals with SMI and co-occurring disorders.12

Professionals in public psychiatry can play an impor- tant role in supporting individuals in residential settings and PSH. Tsemberis and colleagues discuss the role of psy- chiatrists in housing and describe the importance of a team- based approach, with care given to clear communication and a consistent de nition of responsibilities among team members. Flexible psychiatric outreach and engagement and creative treatment strategies to connect with individuals in the community are recommended. ere is also an impor- tant role for professionals in public psychiatry as consultants and liaisons to supportive housing sta and other providers.


e vast majority of persons with SMI and co-occurring disorders are still unable to claim the valued roles of


“employee” or “student” as a core of what they do and who they are. Historically, public mental health systems have tended to divorce the meanings of work and education for people with SMI and co-occurring disorders from the various meanings that work and education have for the gen- eral public.13 For many years, this perspective perpetuated models of care in which participation in work or school was viewed primarily as something that came a er an individual had successfully completed treatment and achieved clinical stability. is view neglects the fact that meaningful jobs and education are not the reward at the end of the recovery journey but more o en the reason a person takes the rst step toward wellness.


Traditional models of vocational rehabilitation (VR), such as sheltered or protracted “train-and-place” approaches, have been harshly criticized as being (1) disrespectful of the preferences and potential of those accessing VR services, (2) inaccessible to the majority of people with SMI and co-occurring disorders, (3) poorly integrated with clinical services, and (4) unreasonable in the compliance expecta- tions placed on those accessing VR services.14 Individuals with SMI and co-occurring disorders served in such mod- els could literally spend years, if not decades, “getting ready to work” without ever actually spending a single day in a “real job.”15 For these reasons and more, pre-vocational and transitional approaches began to fall by the wayside in the early 1990s as public mental health systems began to adopt promising alternative rehabilitation interventions, collec- tively referred to as “supported employment” (SE).

Unlike other vocational approaches, SE programs do not “screen” people for work readiness, but help all who say they want to work; they do not provide pre-vocational or intermediate work experiences, and they actively facilitate rapid job acquisition and o en send sta to accompany indi- viduals on interviews and job sites.16 SE stresses on-the-job training through individualized vocational support plans in recognition of the fact that work behavior is best learned in its natural setting. SE, recognized as an evidenced-based practice for more than a decade by the SAMHSA provides support, instruction, and supervision that are initially intensive then decrease as the individual achieves greater independence. However, the model does not assume that all people will achieve full, autonomous functioning over time. In recognition of this, supports are continuous and are tailored based on individual need. is feature helps to avoid the all-too-frequent situation wherein initial services are withdrawn according to arbitrary time parameters thus

leaving insu cient supports to promote job retention in the competitive employment arena.17

One speci c SE approach, the Individual Placement and Support (IPS) model developed at the New Hampshire– Dartmouth Psychiatric Research Center, has been able to e ectively embrace and implement the multiple principles of SE in furthering the community work tenure of people with SMI and co-occurring disorders.18,19 In addition to the SE principles just described, a core delity feature within the IPS model is the integration of vocational and clinical services in one comprehensive interdisciplinary team.

Although IPS emerged in community mental health centers less than 25 years ago, the empirical foundation for the e cacy of the model has been well established. IPS is three times more e ective than other vocational approaches in helping people with SMI and co-occurring disorders to work competitively.20 Similar positive e ects have been consistent for nonvocational outcomes as well, such as improved self-esteem, enhanced quality of life, and reduced symptoms.21 e model has been found e ective for numer- ous populations for which it has been tried, including peo- ple with many di erent diagnoses, educational levels, and prior work histories.22 Finally, IPS is an excellent investment because studies have demonstrated a signi cant reduction in community mental health treatment costs for people receiving SE largely due to associated decreases in psychiat- ric hospitalization days and emergency room usage.23


Cognitive impairments are a common feature of SMI and co-occurring disorders and are more closely related to functional disability than clinical symptoms. Moreover, they are o en present before the onset of illness and per- sist in the absence of other clinical manifestations of ill- ness. ese impairments o en occur in multiple domains including attention, verbal memory, visual memory, pro- cessing speed, and executive function.24 ey are likely to be most impaired in schizophrenia and related psychotic disorders, but cognitive impairments are also reported in bipolar disorder, depression, and post-traumatic stress dis- order. ese impairments may be rate-limiting factors in the recovery of lost function due to psychiatric illness25 and, for that reason, have become targets for pharmacological and behavioral interventions. Although no psychopharmaco- logical agents have yet demonstrated cognition-enhancing e ects, there is growing evidence that cognitive training that takes advantage of the brain’s neuroplastic capacity for experienced-based changes may be e ective in improving


neurocognitive performance. When combined with acti- vating rehabilitation programs, these improvements may lead to signi cant functional improvements.26

For example, recently, a series of studies found that computer-based cognitive remediation that provided exercises that trained attention, memory, and executive function in both verbal and visual domains could improve neurocognitive per- formance and lead to signi cant improvements in work perfor- mance over time. Moreover, these studies demonstrated that when cognitive remediation was combined with SE services, participants were more likely to achieve competitive employ- ment and to work more hours and earn more money over a two-year period than those who received SE without cognitive remediation.27,28 Cognitive remediation was found to be most bene cial for those participants who had poor community function at baseline.29 us, it appears that cognitive reme- diation, when combined with rehabilitation programs, may be especially bene cial to those who need it most—people in recovery less able to do well in the community.

ese encouraging ndings suggest that systematic learn- ing approaches founded on growing neuroscience under- standing of brain plasticity may have broad applications for psychiatric rehabilitation and recovery. Computer-based cognitive training methods are evolving rapidly and becom- ing more sophisticated, targeted, and user-friendly. ey pro- vide the person with greater autonomy and choice because the person being trained may have the option of using these programs at home or in the clinic, and the programs may be shaped to the person’s interests and needs. e focus of such training is on positive change and self-improvement, with the cognitive training specialist serving as facilitator and guide. e adaptive nature of computer-based training ensures that the tasks provide the optimum amount of challenge (neither too easy nor too hard) so that the person experiences earned success. ese successes may increase motivation and self- con dence as well as improve cognitive performance. ese successes may then make it more likely that the person will get the most out of the opportunities provided by SE and other PSR and recovery programs.


SMI and co-occurring disorders o en emerge in late ado- lescence or early adulthood and interrupt the attainment of typical educational milestones (e.g., a high school diploma or completion of postsecondary academic or technical training programs). Even in systems of care where evidence- based SE is more widely available, the absence of these edu- cational milestones may limit people to entry-level, low-pay,

or part-time positions that relegate them to a life of pov- erty and dependence on state and federal entitlement pro- grams. In a recovery-oriented system of care, “employment services” should, therefore, be conceptualized broadly to include supported education (SEd) as a critical element of meaningful career development.

SEd, designated as a promising practice by the SAMHSA,30 is a recovery-oriented practice that was devel- oped to assist individuals with mental illness who want to start or return to school to complete their educational goals.31 Although SEd is generally geared for postsecond- ary education, it has also assisted people in getting their General Education Diploma (GED) to help them apply to college or vocational technical school. A comprehensive program of SEd should include methods to strengthen basic educational competencies, immersion in a normalizing educational environment such as a college campus, access to recreational and cultural resources, opportunities for career planning, and professional support for navigating academic environments and negotiating necessary accommodations and peer support from other SEd students.32 SEd also places a strong emphasis on the need for systems-level change and the widespread o ering of awareness building to decrease stigma and increase support for students living with SMI and co-occurring disorders. Successful SEd projects there- fore involve collaborative work and the sharing of resources among multiple stakeholders, including students, instruc- tors, family members, tutors, classmates, SEd alumni, and mental health providers.

Research has demonstrated numerous bene ts from involvement in SEd programs including decreased hospital- ization33 and increased educational attainment, competitive employment, self-esteem, and personal empowerment.34,35 More recently, pilot projects combining the interventions of SE and SEd have shown highly promising results, with nearly half of those completing the intervention working in the skilled occupation of their choice at the conclusion of the study.36

Service users participating in SE and SEd echo these diverse bene ts when describing how participation in work and school helps them achieve a sense of “normalcy” despite the in uences of the illness. is phenomeno- logical process is poignantly illustrated in the following statement made by an individual living with a serious psy- chiatric disorder:

It lessens the stigma for me, my own personal stigma and how I feel about myself having schizophrenia. I feel more of a normal person. I feel more of a capa- ble person, that I’m just as good as anybody else.37


In summary, many individuals identify the pursuit of employment and higher education as a critical ingredients in their personal growth, recovery, and sense of commu- nity belonging. e valued roles of “employee” or “student” are particularly crucial for people living with SMI and co- occurring disorders because they a ord them the opportu- nity to de ne themselves as something other than “mental patients”38,39 in a service system and society that has tradi- tionally focused on pathology rather than competency.


As discussed in Chapter 3, the discipline of peer support is a growing area of service provision within public psychia- try and a key element of recovery-oriented care. Emerging from the addictions eld and the consumer-survivor move- ment,40 peer support has a growing evidence base, national recognition, and a burgeoning labor force last estimated at 10,000–15,000 in the United States.41 Peer support can play a central role in strategies that promote community inclu- sion for individuals with SMI and co-occurring disorders.42 is section o ers brief highlights of this important area of practice; see Chapter 3 for a more detailed discussion.

Peer support involves persons in recovery from mental illness working in roles to support others in their recov- ery journeys and is de ned by Mead as “a system of giving and receiving help founded on key principles of respect, shared responsibility, and mutual agreement of what is helpful.”43 Peer support sta share their own experience of mental illness and/or addiction to provide support, hope, and education, and they serve as role models. As a service delivery model, peer support dates back to the early 1990s, but historical roots extend to France in the late 18th cen- tury, with other examples across the centuries.44 Titles of people in this role may include peer support specialist, recovery coach, recovery support specialist, peer mentor, peer coach, and others.45

Peers provide a wide range of supports in a variety of set- tings including individual support, groups, education, case management, advocacy, employment support, skill develop- ment, support around developing recovery plans, and facili- tating speci c curricula such as Wellness Recovery Action Plan,46 a commonly peer-provided evidence-based self- directed wellness tool. Peers o en act as a bridge to clini- cal providers, educating people about what to expect from clinicians and alleviating common fears and misconcep- tions, particularly early in treatment.47 A recent article also identi es peers as potential consultants to public psychia- try professionals in training, acting as advisors to clinical

work.48 Johnson and colleagues49 found signi cant positive impacts on recovery and quality of life for those working as peer support specialists, a nding illustrated by this quote from a provider: “getting back to work as a peer provider makes me feel good; makes me understand I can do [recov- ery]”.50 A range of certi cation processes exist in 37 states as of 2012.51 Many states reimburse for peer-provided ser- vices through the Medicaid Rehab Option,52 and the prac- tice is growing within the Veterans Health Administration as well.53 A national professional organization, the International Association of Peer Supporters (, emerged in 2004, with practice standards for the discipline currently in development. Nevertheless, many challenges within peer support as a discipline persist, including the risk of being co-opted by—and the challenge of retaining one’s “peerness” in the face of—more traditional mental health systems and how to create truly mutual relationships in the context of the medical model.54 Peer sta also encounter discrimination in the workplace and may also encounter fears among clinical sta that the peer will “decompensate,” thus becoming a burden rather than an asset to treatment teams,55 despite research evidence to the contrary.

e evidence in support of peer programming is increasingly robust and promising. Evidence shows that peer support increases empowerment, helps reach peo- ple di cult to engage,56 and inspires hope.57 In a recent overview of peer support, Chinman and colleagues58 con- sidered the evidence strength “moderate” and identi ed improvements in the following six outcomes: reduced inpatient use, improved relationship with providers, bet- ter engagement with care, higher levels of empowerment, higher levels of activation, and higher levels of hopeful- ness for recovery.

One of the unique qualities of peer support is “condi- tional regard” and the ability to “call someone out” based on the legitimacy granted by a shared experience, illustrated by the quote here:

I had been sitting back letting other folks call the shots, and then complaining when things got messed up. A Peer Specialist at the advocacy center called me out on it. I realized that I had gotten com- fortable letting other folks make decisions for me, and I know now that I gotta take charge of my own recovery.59

As an essential part of an interdisciplinary team, peer support adds a unique resource for people with mental ill- ness and for promoting recovery. As well as serving as role models for clients, peers are living examples of recovery and


remind providers of its possibility, thus acting as advocates and assisting in decreasing discrimination. Peer support can be especially helpful in working with those who are harder to engage into care and who are mistrustful of the mental health system. A key point for professionals in public psy- chiatry is acknowledging that peer support team members are sta just like other sta , but can o er their unique per- spective to the work and can provide invaluable insights around care.


Successful strategies for community inclusion depend, in a large part, on the identi cation, coordination, and integra- tion of any and all community supports, be they housing, employment, education, peer, social supports, and/or life skills based on an individual’s particular needs. PSR is an approach that can bring all these pieces together. PSR has been conceptualized in many ways but is de ned gener- ally as a process or approach that utilizes a broad variety of techniques, many of them evidence-based, to help an indi- vidual reach his or her highest potential or highest individ- ual community functioning.60–62 In addition to supported housing, employment, education, and peer supports, as discussed previously, core PSR practices include Assertive Community Treatment (ACT) (see Chapters 13 and 17), Medication Management (see Chapters 12 and 17), Family Psychoeducation (see Chapters 10 and 17) and, as will be discussed later, interdisciplinary case management, training to improve life skills, fostering of natural social supports, and clubhouses.


Case management is a key component in assisting peo- ple with SMI and co-occurring disorders to succeed in community-based living.63,64 Case management services for adults with SMI and co-occurring disorders provide care and/or care coordination for needs including physi- cal health, mental health, housing, employment, social roles, and community integration goals. In so doing, case management addresses each of the SAMHSA’s four dimensions for recovery: health, home, pur- pose, and community. Interdisciplinary case manage- ment is a team-based service that utilizes the skills and discipline-speci c expertise of team members to provide

a holistic approach to providing and/or coordinating care.65,66 Interdisciplinary case management is o en cen- tral to—if not essential in—determining a compre- hensive and holistic person-centered care plan. To help ensure a person-centered approach, many teams use an organizing tool such as “SNAP” to be sure to include a person’s strengths, needs, abilities, and preferences in the care planning process.67


Life skills training is another core PSR technique, and it may include Illness Management and Recovery (IMR) or similar evidence-based programs of self-management, such as money management68 and social skills training.69 IMR is a curriculum developed to help people with SMI and co- occurring disorders understand recovery, set goals for mov- ing forward, gain greater understanding of mental illness and its treatment, develop medication support regimens and relapse prevention plans, learn coping skills for symptom management, and improve social support. Whereas IMR is a multifaceted approach drawing on several evidence-based practices including Cognitive Behavioral erapy (CBT), money management and social skills training target a spe- ci c area of need.


Fostering natural supports can include helping with the development of new relationships, the strengthening of current relationships, family reuni cation, and, ulti- mately, expanding roles within communities or groups with shared interests or values such as the arts commu- nity, faith community, and 12-step programs. Natural supports are best characterized as “naturally occurring, [largely] bi-directional and mutual relationships.”70 Like most PSR techniques, fostering natural supports neces- sitates in vivo work, so that context and group norms, among other variables, can be understood and the care team can best assist the person in building or strengthen- ing social connections and supports.


Clubhouses are one of the best known models within PSR. e rst clubhouse, which established the model, was FountainHouse,locatedinNewYorkCityandestablishedin 1948 by people who had previously formed a self-help group a er their discharge from a nearby state hospital.71 e club- house model is a member-driven therapeutic community


in which members have speci c rights and responsibilities, including self-governance, through which the model pro- motes hope and empowerment.72 Clubhouse International, the accrediting body for clubhouses, considers a clubhouse to be a “local community center” with a focus on employment for members, either as a paid worker in the community or as

a volunteer in the clubhouse working in various aspects of the program. Clubhouses o en o er housing support, case management, supported education, and advocacy. Limited sta are hired by clubhouses. e Clubhouse International website notes that there are 341 clubhouses in 32 countries as of March 2014.73


One way to illustrate the identi cation, implementation, and coordination of community supports on an indi- vidualized basis and the PSR process more broadly is through a brief case vignette. Meet Mr. Harry Harcourt (whose name and other identifying information have been changed to protect con dentiality):

Mr. Harcourt is a 49-year-old white man, currently without housing, who has a diagnosis of bipolar disorder and a substance use disorder. He served in the military om the age of 18–26 and receives a small veteran’s disability bene t. A er the military, he worked in construction and later worked as a tool and die maker, but he hasn’t worked steadily for around 15 years. He has a brother and an aunt living nearby with whom he is not in touch. He identi es as hetero- sexual, has never been married, and has no children. Mr. Harcourt has had several encounters with the police in the past when he drinks. He has multiple medical problems including diabetes, obesity, and congestive heart failure.

Mr. Harcourt has sporadically accessed mental health care through a community mental health center and, at times, a VAhospital.HisphysicalhealthcarehaslargelybeenthroughtheVA.Heusuallyseesanoutpatientpsychiatristformedi- cation management but has needed inpatient care during both manic and depressed episodes several times in the past.

Within a recovery paradigm, the approach to helping Mr. Harcourt includes understanding his strengths, needs, abilities, and preferences (SNAP) so that his care is both holistic and person-centered. is is a rst step for professionals in public psychiatry working as a team to develop a wrap-around care plan.

Strengths: Mr. Harcourt honorably served in the military and has a small pension income and access to VA health care due to his veteran status. He has valuable work skills (carpentry, tool and die) and a high school education. Mr. Harcourt also has relatives who live near him and who may be a source of support.

Needs: Mr. Harcourt’s needs om a health provider’s point of view are his mental and physical health care, followed by his lack of safe and a ordable housing. Mr. Harcourt indicates that working, addressing legal problems, and improv- ing his relationship with his family are his primary needs.

Abilities: Mr. Harcourt is a strong self-advocate. He is able to voice his needs easily and will advise providers when his needs are not being met. is is sometimes viewed by providers as being disruptive or “noncompliant.”

Preferences: Like many people, Mr. Harcourt is not able to easily articulate treatment preferences without assistance in determining which services in his care system are under his control. With assistance om his team, he indicates he prefers not to come to a mental health center for treatment and would like the opportunity to work with a peer who he feels may better understand his struggles.

A er completing the SNAP assessment, the care team and Mr. Harcourt are able to develop a holistic view of his current situation, priorities, and needs. ey decide that interdisciplinary case management using an ACT model will allow Mr. Harcourt to be served in the community and would be the best approach given his complex needs. Within this model, a number of steps and approaches are identi ed and recommended to Mr. Harcourt. ese include:

1. IMR skill building, including an emphasis on continuing medication management and the introduction of peer supports to address Mr. Harcourt’s mental health and substance use.

2. A case manager who is designated to support Mr. Harcourt during initial meetings with his lawyer in order to address his legal issues.


3. A referral to supported housing. Although housing is not a stated priority for Mr. Harcourt, he agrees that stable housing would ultimately be to his bene t, considering his employment needs and primary health issues.

4. Supported employment. Mr. Harcourt is connected with the SE specialist on his interdisciplinary care team, and, a er an assessment, they immediately pursue a competitive employment placement with supports.

5. erapy. Mr. Harcourt and his care team agree that, among other things, therapy will focus on helping him rebuild relationships with his aunt and brother, and the team will provide assistance in reaching out to them.

6. Finally, although Mr. Harcourt is ambivalent about giving up alcohol and making social connections,
Mr. Harcourt and his care team identify community resources such as Alcoholics Anonymous and a local Clubhouse with a wide variety of available daily activities for him to consider. rough discussions with
his care team and the use of motivational interviewing, Mr. Harcourt realizes that sobriety and use of these community supports can have a positive impact on achieving many of his goals, including those related to legal issues, employment, and family relationships.

With all of these supports in place, Mr. Harcourt is able to make slow and steady progress in achieving his goals.


e Health Resources and Services Administration74 de nes quality improvement (QI) as consisting of “systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted popula- tions.” A review of QI data for agencies that provide supports for individuals receiving publicly funded community-based psychiatric services can help professionals in public psychia- try understand both the impact of the services for their cli- ents and also clients’ perceptions of the care provided.

Although many community-based providers are required by their funders to collect and report client and services data, many of these agencies do not utilize these data to under- stand the impact of their services or to improve the quality of care provided. As a requirement of the Federal Community Mental Health Services Block Grant program,75 states must report data on a myriad of outcomes including employ- ment/education, stability in housing, social connectedness, access to care, client perceptions of care, and criminal jus- tice involvement. With the goal of helping providers utilize collected data, some localities have implemented a network of care approach, which, along with other services and sup- ports, provides core support to help build the capacity of community providers to employ a QI process.76

In an e ort to promote transparency and service devel- opment, some states post on the Web a “dashboard” or summary of outcomes for each program they fund.77 ese reports provide information for both consumers and pro- viders that can be helpful in determining the most appro- priate service t and promote QI: for example, given the consensus in the consumer literature that services are ben- e cial when they facilitate recovery.78

Consumer perspectives of care are an essential outcome to consider. For professionals in public psychiatry who work from a recovery orientation, the review of consumer satisfaction data provides an opportunity to understand if a community provider shares this orientation and, if not, there is an opportunity to address this discrepancy.


Community inclusion should be the shared commitment of all providers in public sector mental health. In addition, the creation of a wide spectrum of community-based care resources introduces a challenge with regard to its integration with other treatments. e following paragraphs detail rec- ommendations for professionals in public psychiatry to maxi- mize their contributions in an evolving recovery-based system of care for persons with SMI and co-occurring disorders.

In clinical practice and organizational leadership, pro- fessionals in public psychiatry should actively encourage and support all people in exploring and pursuing resources and opportunities that lead to socially valued community roles. Housing, employment, education, and social life are, for all people, usually the foundation for such roles.

Psychiatric expertise and treatment, including pharma- cological management, need to be reframed so that they are squarely focused on outcomes that are most important to the individual. For example, employment- or school-related goals may call for modi cations to medication schedules to promote maximum energy and cognitive functioning at certain times during the day. e care team may also need


to discuss with the person how symptoms and side e ects impact work or school performance and to brainstorm per- sonal management strategies.

Professionals in public psychiatry should be mindful of referral procedures that preclude certain people from access- ing supported housing, employment, education, and other resources. In some systems, people are still screened for “readi- ness” in one or more of these areas and are unable to access services unless they are deemed to be functioning at a high enough level. In general, readiness screening has no place in a recovery-oriented system of care, and professionals in public psychiatry can advocate for a science-based “zero reject pol- icy” that does not exclude people based on symptomatology, substance use, or unwillingness to participate in community supports.

Along these same lines, many people served by the com- munity mental health system o en have substantial fears and doubts regarding their ability to pursue meaningful lives in the community and valued social roles a er having heard the message for years that they “are not ready” and being repeatedly asked “what if you relapse?” Professionals in public psychiatry can play a critical role in addressing these fears by consistently sending the message that partici- pation in their community of choice through supported housing, work, education, or other opportunities is funda- mental for mental health and wellness.79

As team leaders and policy-makers, all professionals in public psychiatry can embrace the emerging best practice of person-centered recovery planning (PCRP) as a pow- erful tool in helping people to return to or continue in valued social roles. Person-centered planning models sup- port individuals with SMI and co-occurring disorders to discover (or rediscover) themselves as healthy persons with a history, a future, and with strengths and interests beyond their clinical de cits or functional impairments. As such, PCRP is highly complementary to strategies for commu- nity inclusion, and professionals in public psychiatry are encouraged to develop their knowledge and competencies in this area.

Finally, individuals with SMI and co-occurring dis- orders continue to be the target of damaging and unre- mitting myths and assumptions that contribute to their exclusion from the community. e media is fraught with images of violence committed by people with psychiatric disabilities, despite the fact that there is limited empiri- cal support for such a sensationalized caricature.80 Leading professionals in public psychiatry are uniquely positioned to confront these myths and assumptions and commu- nicate accurate facts within and beyond the community mental health system.


Public psychiatry has undergone a revolution over the past 50 years as the care of people with SMI and co-occurring disorders moved from the hospital to the community. Nowhere is this change more evident than in the emergence of community supports and the goal of community inclu- sion in contemporary practice. is chapter has reviewed the evidence for essential community supports such as housing, SE, SEd, and peer support. Also, it has high- lighted the multiple practices of community-based PSR. Supporting individuals with SMI and co-occurring disor- ders in the community raises the challenge of achieving true community inclusion through an integration of treatment and other essential support based on person-centered care within recovery-oriented systems. A case vignette high- lighted this challenge through the lens of one individual’s set of circumstances, needs, and desires. Finally, the chapter discussed the importance of metrics for evaluating commu- nity supports and inclusion as a way of achieving continu- ous quality improvement.


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43. Mead S. De ning peer support. 2003. http://chrysm-associates. ningPeerSupport.pdf. P. 135. Accessed date: August 28th, 2015.

44. Davidson L, Bellamy C, Guy K, Miller R. Peer support among per- sons with severe mental illness: a review of evidence and experience. World Psychiatry. 2012;11(2):123–128.

45. International Association of Peer Supporters. Peer Support De nition. 2014. nition-peer-specialist/. Accessed date: August 28th, 2015.

46. Copeland ME. Wellness Recovery Action Plan: A System for Monitoring, Reducing and Eliminating Uncomfortable or Dangerous Physical Symptoms and Emotional Feelings. West Dummerston, VT: Peach Press; 2002.

47. Davidson L, Bellamy C, Guy K, Miller R. Peer support among per- sons with severe mental illness: a review of evidence and experience. World Psychiatry. 2012;11(2):123–128.

48. Agrawal S, Edwards M. Personal accounts: upside down: the con- sumer as advisor to a psychiatrist. Psychiatr Serv. 2013;64(4):301– 302. doi:10.1176/

49. Johnson G, Magee C, Maru M, Furlong-Norman K, Rogers, ES, ompson, K. Personal and societal bene ts of providing peer support: a survey of peer support specialists. Psychiatr Serv. 2014;65(5):678–680.

50. Davidson L, Rowe M, O’Connell M, Lawless MS. A Practical Guide to Recovery-Oriented Practice: Tools for Transforming Mental Health Care. Oxford University Press: New York; 2008: 95.

51. Kaufman L, Brooks W, Steinley-Bumgarner, M., Stevens-Manser, S. Peer Specialist Training and Certi cation Programs: A National


Overview. University of Texas at Austin Center for Social Work Research; 2012. specialist-training-and-certi cation-programs-a-national-overview UT 2013.pdf. Accessed date: August 28, 2015.

52. US Department of Health & Human Services, Center for Medicare and Medicaid Services; SMDL 07-11;2007. cmsgov/archived-downloads/SMDL/downloads/smd081507A. pdf. Accessed date: August 28, 2015.

53. Resnick SG, Rosenheck RA. Integrating peer-provided services: a quasi-experimental study of recovery orientation, con dence, and empowerment. Psychiatr Serv. 2008;59(11):1307–1314. doi:10.1176/

54. Braiterman K. Peer support in CMHC’s is an oxymoron, peer support pioneer says. peer-support-in-cmhcs-is-an-oxymoron-peer-support-pioneer-says/ 2008. Updated July 19, 2012. Accessed date: August 28, 2015.

55. Davidson L, Bellamy C, Guy K, Miller R. Peer support among per- sons with severe mental illness: a review of evidence and experience. World Psychiatry. 2012;11(2):123–128.

56. Sells D, Black R, Davidson L, Rowe M. Beyond generic sup- port: incidence and impact of invalidation in peer services for clients with severe mental illness. Psychiatr Serv. 2008;59(11):1322–1327. doi:10.1176/

57. Sledge W, Lawless M, Sells D, Wieland M, O’Connell M, Davidson L. E ectiveness of peer support in reducing readmissions among people with multiple psychiatric hospitalizations. Psychiatr Serv. 2011;62:541–544.

58. Chinman M, George P, Dougherty RH, et al. Peer support services for individuals with serious mental illnesses: assessing the evidence. Psychiatr Serv. 2014;65(4):429. doi:10.1176/

59. Tondora J, Miller R, Slade M, Davidson L. Planning for Recovery in Mental Health: A Practical Guide to Person-Centered Planning. London: Wiley-Blackwell; 2014.

60. Anthony WA, Cohen MR, Farkas MD, Gagne C. Psychiatric Rehabilitation. 2nd ed. Boston, MA: Center for Psychiatric Rehabilitation, Boston University, Sargent College of Allied Health Professions; 2002.

61. Bachrach LL. Psychosocial rehabilitation and psychiatry in the care of long-term patients. Am J Psychiatry. 1992;149:1455–1463.

62. World Health Organization. Psychosocial Rehabilitation: A Consensus Statement. 60630. Issued 2006. Accessed date: January 25, 2014.

63. Horvitz-Lennon M, Kilbourne AM, Pincus HA. From silos to bridges: meeting the general health care needs of adults with severe mental illness. Health A . 2006;25(3):659–669.

64. Mueser KT. e illness management and recovery program: ratio- nale, development, and preliminary ndings. Schizophr Bull. 2006;32(Suppl 1):S32–S43. doi:10.1093/schbul/sbl022.

65. Jessup RL. Interdisciplinary versus multidisciplinary care teams: do we understand the di erence? Austral Health Rev. 2007;31(3):330.

66. Rapp CA, Goscha, RJ. e principles of e ective case management of mental health services. Psychiatr Rehabil J. 2004;27(4):319–333. doi:10.2975/27.2004.319.333.

67. CARF International. 2014 Behavioral Health Program Descriptions. Accessed date: January 25, 2014.

68. Marson DC. Financial capacity in persons with schizophrenia and serious mental illness: clinical and research ethics aspects. Schizophr Bull. 2005;32(1):81–91.

69. Kopelowicz A. Recent advances in social skills training for schizo- phrenia. Schizophrenia Bulletin. 2006;32(Suppl1):S12–S23.

70. Davidson L, Chinman M, Sells D, Rowe M. Peer support among adults with serious mental illness: a report from the eld. Schizophr Bull. 2005;32(3):443–450. doi:10.1093/schbul/sbj043.

71. Macias C, Jackson R, Schroeder C, Wang Q. What is a clubhouse? Report on the ICCD 1996 survey of USA clubhouses. Community Ment Health J. 1999;35:181–190.

72. Jacobs HE, DeMello C. e clubhouse model and employment fol- lowing brain injury. J Vocat Rehabil. 1996;7:169–179.

73. Clubhouse International. Mission. html. Accessed January 25, 2014.

74. Health Resources and Service Administration. Quality improve- ment. 2011. qualityimprovemement/ Accessed date: March 24, 2014.

75. Substance Abuse and Mental Health Services Administration. National outcome measures (NOMS). http://www.samhsa. gov/co-occurring/topics/data/nom.aspx, Accessed date: March 27, 2015.

76. Kaufman, JS, Crusto, CA, Quan, M, Ross, E, Friedman, SR, O’Rielly, K, Call, S. Utilizing program evaluation as a strategy to promote community change: Evaluation of a comprehensive community- based family violence initiative. Journal of Community Psychology, 2006;38(3-4):191–200.

77. Department of Mential Health and Addiction Services. EQMI- Provider Quality Reports Info. 2014. cwp/view.asp?a=2900&q=489554. Accessed date: March 20, 2015.

78. Torrey WC, Wyzik P. e recovery vision as a service improvement guide for community mental health center providers. Psychiatr Rehabil J. 2010;36(2):209–217.

79 Marrone J, Golowka E. If work makes people with mental illness sick, what do unemployment, poverty, and social isolation cause? Psychiatr Rehabil J. 1999;23(2):187–193.

80. Monahan J. Mental disorder and violent behavior: perceptions and evidence. Am Psychol.1992;47(4):511–521.






Aniyizhai Annamalai, Cenk Tek, Michael J. Sernyak, Robert Cole, and Jeanne L. Steiner


• Integrated medical and behavioral health services are imperative for improving the morbidity and mortality of seriously mentally ill people.

• Health care models integrating primary care into behavioral health show early promise for improving health outcomes in this population.

• e Center for Integrated Health Solutions funded by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration promotes integrated care and provides training to community health organizations.

• e A ordable Care Act creates options for providing health homes for those with chronic conditions; although these homes have traditionally been based at primary care centers, there is now opportunity for community mental health centers to serve as medical homes.

• Psychiatrists and other mental health professionals can be at the forefront of integrated health care in the era of health care reform.


People with serious mental illness (SMI) frequently have comorbid general medical conditions, and this largely accounts for the shortened life expectancies of those with SMI compared with the general population.1 In addition to patient and provider factors, health care system factors contribute signi cantly to the poor quality of medical care. For example, patients receiving care at community mental health centers have problems with access to care and receive a lower quality of primary care than does the general popu- lation.2 Traditionally, general medical care is segregated from mental health care. Medical and behavioral health sys- tems are not colocated, o en do not share information, and have separate funding streams.3

ese challenges are faced by community mental health centers where the majority of SMI population is seen. A survey of leaders at these mental health centers indicated

that even though more than two-thirds reported protocols to screen for common medical conditions, only half could provide treatment and referral sources, and only a third could provide medical services on site. Barriers to medi- cal care include insu cient physical infrastructure on site, reimbursement issues, and lack of referral sources.4

Among integrated care models, those in which mental health providers are brought into medical settings have been well-studied. More recently, models in which medical pro- viders are brought into behavioral health settings are being implemented. Interventions designed to improve medical care in persons with mental illness have shown improved linkage with primary care, better quality of primary care, and some improvement in medical outcomes.5

In this chapter, the authors review the need for inte- grated care among those with SMI and commonly encoun- tered medical comorbidities, describe di erent models of integrated care and required competencies for an integrated


practice setting, and then outline the concepts and struc- ture of a medical home. e authors then use a case example to illustrate clinical and administrative challenges in imple- menting an integrated clinic.



By the 1990s and early 2000s, momentum grew for the development of national policies and initiatives regarding integrated care within the public sector. ere was clear evidence that individuals with serious mental illness were not utilizing the health care system e ectively, o en using emergency rooms rather than outpatient settings to meet their medical needs.6 One study conducted at Yale demon- strated that patients enrolled at the Connecticut Mental Health Center experienced lower access to medical care than did the general population, as well as lower quality of care in four essential domains: care provided at rst contact, ongoing care, comprehensiveness of care, and coordination of care.2

e Bazelon Center published a report in 2004 out- lining “How to Integrate Physical and Mental Health Care for People with Serious Mental Disorders,” one of the rst publications to address new models of integrated care within the context of a recovery-oriented mental health system.7

e Medical Director Council of the National Association of State Mental Health Program Directors (NASMHPD) published a comprehensive blueprint for integrated care within state mental health authori- ties.8 Under the auspices of the National Council for Community Behavioral Healthcare, which published its own reports in 2006, the leaders of these entities pro- vided a template for mechanisms to improve health care outcomes for individuals who receive services in the pub- lic sector.9


An analysis of 10,084 patients at public mental health facili- ties showed high rates of obesity and metabolic syndrome in patients with schizophrenia, bipolar disorder, and other SMI.10 Rates of obesity (body mass index [BMI] ≥ 30) and hypertension (blood pressure [BP] ≥ 130/85) were greater

than 50%. Elevated glucose levels (fasting ≥ 100) were seen in 33% patients. An abnormal lipid pro le was seen in more than half of patients. Among those with metabolic syndrome, 60% were not receiving treatment. Among those being treated, more than 50% continued to have high lev- els of BP, cholesterol, and blood sugar. Similarly, baseline data from the Clinical Antipsychotic Trials of Intervention E ectiveness (CATIE) study showed that more than 40% of patients had metabolic syndrome.11 In this sample, the 10-year risk for coronary heart disease for patients with schizophrenia was signi cantly increased compared to a control population.12 Treatment rates for these metabolic disorders are low in the SMI population.13 In addition to metabolic syndrome and cardiovascular risk, people with SMI are also at higher risk for other chronic conditions such as hypothyroidism,14 chronic obstructive pulmonary disease,14,15 hepatitis C, HIV,14,16 obstetrical problems, and dental issues.16


e etiology of increased medical comorbidity in people is manifold and related to provider factors, patient fac- tors, treatment variables, and issues with access to quality primary care.

Healthcare Providers

Traditionally, psychiatrists have distanced themselves from physical health evaluations. In a 1978 survey of practicing psychiatrists, none was found to perform physical exami- nations in their outpatient practice. ose in inpatient practice delegated the hospital admission physical exami- nation to others.17 Medical diagnoses were missed in more than 50% of patients in a 1989 study done in a state mental health facility.18 In later years, even with the advent of newer psychotropic medications that cause or exacerbate chronic medical conditions, psychiatrists did not focus on preven- tive health screening or physical health.19

In more recent years, it has been reassuring to note that psychiatric providers do have an increased awareness of the risks of psychotropic treatment regimens and the need to tailor treatment based on metabolic risk factors.20 However, it is unclear if this knowledge and awareness translates into the greater involvement of psychiatrists in physical health care. Primary care physicians may not be comfortable caring for the medical needs of people with SMI due to a perceived need for specialized care.21 And, with competing demands on their time, primary care physicians may not have the


resources to address the special needs of severely impaired, mentally ill patients.

Patient Factors

Patients with SMI have cognitive impairments across sev- eral neurocognitive domains limiting their adaptive and social functioning.22 is a ects their ability to adapt to the fast-paced environments found in a typical medical clinic and to communicate e ectively with health care providers. Noisy and crowded waiting areas were cited as one of the barriers in accessing primary care by people with SMI.21 Poor understanding of physical illness, inability to navigate complex health care systems, lack of motivation to follow through on treatment, and fear and mistrust of providers who are not familiar to them can all contribute to patients with SMI not engaging in primary care.

Symptoms of psychiatric illness such as paranoia and severe depression or anxiety also in uence patient behaviors. Patients also may not have adequate social and economic resources to adhere to healthy lifestyles. Furthermore, adverse life experiences signi cantly impact physical as well as mental health.23

Adverse E ects of Pharmacologic Treatment

Patients with SMI are usually on treatments that include psychopharmacologic agents. In the past two decades, there has been a tremendous increase in use of second-generation antipsychotics.24 Many of these contribute signi cantly to obesity and metabolic syndrome, although there are varia- tions in the magnitude of risk among di erent agents.25 is leads to an increased cardiovascular risk, especially with those agents associated with greater changes in weight.26

Access to Medical Care

Access to primary care is a signi cant barrier in the medi- cal care of people with SMI and contributes to poor out- comes.4,27 e mental health sector is the only site of health care for the majority of people with SMI. However, the treat- ment model in mental health settings has mostly been cen- tered on treatment of psychiatric disorders. Organizational supports that facilitate coordinated medical and psychiat- ric care are infrequent. Funding streams for mental health care are o en separate from those for medical care. As a result, the cost bene ts of preventive care and improved medical outcomes accrue outside the mental health system. Hence, the nancial incentive for medical screening and treatment within mental health settings is not compelling.

Information exchange between mental health and primary care providers is limited by restrictive policies and overzeal- ous adaptation of the Health and Insurance Portability and Accountability Act (HIPAA) of 1996.


All mental health professionals can and should play a role in the prevention and treatment of disease. e role of psychi- atrists, especially in the public sector, may be changing with health care reforms and the push toward integrated care.28 Many continuing medical education programs at scienti c meetings now provide content intended to enhance the primary care skills of psychiatrists. Some innovative educa- tional curricula are being developed in psychiatry residency programs to address this need.29 In their role of promoting health for their patients, at a minimum, psychiatrists must minimize the deleterious e ect of the medications they prescribe and conduct appropriate screenings for chronic medical conditions, especially those a ected by psychotro- pic medications. Addressing medication side e ects early in treatment is crucial in preventing long-term morbidity. Psychiatrists are trained to be experts in behavior change and can be in the forefront of preventive counseling in life- style issues, treatment adherence, and self-management of chronic conditions. Psychiatrists, who train in basic medi- cine as well as behavioral health, are uniquely quali ed to be leaders in integrated health settings. Finally, psychiatrists may need to provide some treatment of medical conditions for those mentally ill patients who are unable to access care or unwilling to receive care in primary care settings. is last role is probably the most debated at this time.

All mental health professionals should also play a role in promoting health and wellness. Wellness goes beyond disease management and refers to a holistic approach to health. e focus is on active patient participation in a life- style that promotes physical, social, spiritual, intellectual, nancial, occupational, environmental, and emotional well-being.30 Part of enhancing wellness is engaging in ill- ness prevention activities such as healthy eating, maintain- ing physical activity, and avoiding harmful practices such as tobacco use. e Center for Integrated Health Solutions (CIHS) at the Substance Abuse and Mental Health Services Administration (SAMHSA) provides a guide to a number of wellness strategies.31

Counseling on wellness strategies for a healthier life- style can be provided by nonphysician professionals such as nurses, social workers, mental health workers, and case managers. A growing number of people with a diagnosis of


mental illness have become providers of psychiatric reha- bilitation in the last few decades (see Chapters 3 and 4 for a more extensive discussion on the role of peer support in mental health care); these specialists are more recently inte- grating health and wellness into the concept of recovery.30 Peer support among those with SMI is known to increase satisfaction in various life domains and the ability to e ect changes among participants.32 Peers can help deal with the challenges of maintaining healthy lifestyle activities such as increasing physical exercise or eliminating tobacco use. Peers can also help bridge the gap between patients and physicians by providing education on treatment and facili- tating appointments and referrals.

A public health approach to improving the medical care of those with SMI includes primary prevention by modify- ing risk factors for chronic illness, secondary prevention by screening for medical conditions, and tertiary prevention by providing treatment for existing chronic medical condi- tions to reduce disability. A multidisciplinary team-based approach is required to achieve these goals. A brief review of selected medical conditions follows in the next section.


Obesity and Metabolic Syndrome

SMI patients who typically utilize community mental health services are likely to su er from two or three times higher rates of obesity than the general population.10 is is partly related to socioeconomic reasons but mostly due to the weight-producing e ects of psychiatric medications that are commonly used in this population. Given that obe- sity is at epidemic proportions in the general population, SMI patients are likely to be overweight when they initially receive services. When they are started on medications (mainly antipsychotics), they rapidly gain weight, which rst leads to an increase in a constellation of risk factors commonly referred to as metabolic syndrome. Metabolic syndrome eventually leads to a multitude of diseases, mainly diabetes and cardiovascular disease.33,34

Metabolic syndrome denotes an increase in risk factors for diabetes and cardiovascular disease. It is not a disease in itself and does not have a treatment. On the other hand, components of the metabolic syndrome, such as obesity, hypertension, high cholesterol, and impaired glucose tol- erance, require treatment to prevent the loss of health- related quality of life, excess morbidity, and early mortality observed in SMI populations.

Psychiatrists can play a major role in management of obesity. As with any medical illness, primary prevention is key. Metabolic syndrome almost always follows obesity;

thus, prevention of obesity, if at all possible, will have sig- ni cant health bene ts decades later. Primary prevention of obesity in community mental health starts with medi- cation selection. Practitioners must be keenly aware of the weight increase liability of di erent psychiatric medications and attempt to use the least weight-producing medications. Regardless, some patients will gain weight on the rst medi- cation that they are prescribed. Rapid weight gain is a per- fectly good reason to switch medications, and available data show that medication switch to medications with lower weight liability produces metabolic bene ts.35

e second leg of prevention is utilization of lifestyle interventions that are shown to be e ective in the treatment of obesity as well as its prevention.36 Lifestyle interventions are based on nutritionally informed cognitive behavioral therapy (CBT) principles that can be provided with mini- mal educational burden and relative ease. Clinicians at com- munity mental health centers who are already familiar with the cognitive behavioral component of these interventions can perform this therapy. e authors suggest using lifestyle interventions early in the process, before overweight turns into obesity. Simple changes such as weekly self-monitoring on relatively inexpensive bathroom scales; reduction or elimination of calorie-dense foods from the diet, such as sugared beverages and candy bars; increased everyday activ- ity, such as switching to stairs instead of elevators or increas- ing the amount and speed of walking; stimulus reduction, such as changing shopping habits and eliminating high- calorie foodstu from the household environment; and stress management techniques can be e ective. ese strat- egies, as well as learning to recognize nonhunger emotional eating, go a long way in reducing weight in a consistent and steady manner. ese and other suggestions are compo- nents of manualized lifestyle interventions and can be read- ily accessed for free on the Internet.37 Small improvements in body weight have been shown to provide disproportion- ately large health bene ts.38

For patients for whom metabolic syndrome has already set in, lifestyle interventions and a medication switch to lower weight-liability agents need to be supplemented with medical treatment for high BP and high cholesterol. ese patients need to be monitored regularly for the early detection of diabetes. e antidiabetic medication met- formin has not only been shown to delay development of diabetes for patients with metabolic syndrome, but also to provide modest weight loss regardless of SMI or anti- psychotic use status.39 e authors suggest using metfor- min early on, when signs of impaired glucose tolerance are discovered through regular monitoring, even if diabetes diagnosis is not present.


Pharmacotherapy for obesity is a burgeoning eld, and new medications are developed and approved every day. Unfortunately, many of these medications are centrally acting, with psychiatric side e ects. Currently, the data on using obesity medications in SMI populations are very lim- ited, and familiarity with the medications and caution is required. Some psychotropic medications commonly pre- scribed by psychiatrists are approved as weight loss medi- cations; examples are topiramate, the use of which may be limited by neurocognitive side e ects, and naltrexone/ bupropion, for which evidence of safety and e cacy in SMI is limited.

Finally, for very obese patients or obese patients with medical problems, bariatric surgery provides intensive weight loss and signi cant bene ts, including remis- sion of diabetes. Evidence for bariatric surgery is good in SMI patients with a ective disorders40; however, there is extremely limited evidence for schizophrenia spectrum patients. Patient selection is key due to intensive and criti- cal compliance requirements both pre- and post-bariatric surgery. Regardless, bariatric surgery can be utilized with eligible SMI patients in the context of close collaboration between surgical and mental health providers.

Tobacco Dependence

More than 50% of adults with SMI are tobacco smok- ers.31,41,42 Smoking is a known risk factor for cardiovascular disease, lung cancer, chronic obstructive pulmonary disease, and reduced life expectancy.43 Smoking also plays a causal role in multiple other health conditions, such as other malignancies, bone disease, reproductive disorders, gastric ulcers, and periodontal disease. Smoking cessation dra- matically reduces morbidity and mortality,44 and mortality bene ts can be seen as early as 1 year a er quitting. In the SMI population, smoking adds to the already high burden of medical morbidity. In addition to cardiovascular dis- ease, the prevalence of pulmonary diseases such as asthma, chronic obstructive pulmonary disease, and obstructive sleep apnea (OSA) is high in patients with SMI.15,45–47 ese conditions are aggravated by smoking and independently contribute to physical morbidity and mortality. OSA is also a signi cant risk factor for cardiovascular disease.

People with SMI have lower rates of success with smok- ing cessation.41 Smoking cessation can be harder for people with SMI due to the mood altering e ects of nicotine, higher levels of stress, social factors such as poor education, lower motivation due to psychiatric symptoms or cognitive defects, and poor access to resources for help quitting.48 Pharmacological therapies licensed in the United States

are varenicline, bupropion, and nicotine replacement therapy (NRT). In the general population, varenicline has shown superior e cacy to bupropion and single NRT and equivalent e cacy to combination NRT.49 Most studies of smoking in people with SMI show good tolerability and e cacy of all three agents. Psychosocial interventions are o en combined with pharmacological treatment, and these include supportive group therapy, cognitive behavioral approaches, social skills training, and contingency mon- etary reinforcement.

Relapse rates were found to be high a er abstinence following smoking cessation therapy.50 More recent studies have found maintenance treatment for up to 1 year to be e ective in reducing relapse rates with bupropion, NRT,51 and varenicline in combination with CBT52 in the SMI population.

e role of psychiatrists and other mental health pro- fessionals in smoking cessation ranges from advocating for smoke-free mental health facilities, education on the risks of smoking and bene ts of cessation, providing both behavioral and pharmacologic treatment, and referral to appropriate community resources. Weight loss and smok- ing cessation are the cornerstones for prevention and man- agement of many of the illnesses mentioned here. (See Chapter 6 for a further review of tobacco dependence in people with SMI, recommended assessment and treatment modalities, and available community resources for smoking cessation.)

Infectious Diseases

Adults with SMI are more likely than their counterparts without SMI to engage in risky behaviors associated with sexually transmitted diseases.53 ese behaviors are corre- lated with factors related to psychiatric illness, substance use, cognitive capacity, and social relationships. People with SMI have a high prevalence of HIV,54 as well as other infec- tious diseases such as chronic hepatitis and tuberculosis.55 Data on the prevalence of syphilis in SMI are limited, but it is known to coexist in patients infected with HIV, and the prevalence may be high due to high numbers of people with SMI and comorbid HIV.

e Centers for Disease Control provides guidelines on testing for these and other infectious diseases. Screening for tuberculosis is recommended for those with a close contact with tuberculosis; a person with a immunosuppressive dis- ease such as HIV; and those who live in homeless shelters, jails, or nursing homes. Testing for syphilis should be rou- tinely performed in pregnant persons, those who engage in sexually risky behaviors, and in at-risk groups such as men


who have sex with men. HIV screening is recommended for patients in all health care settings, and in high-risk patients it is recommended annually. Screening for hepatitis C is recommended for those at risk, such as injection drug users, those infected with HIV, and as a one-time test for those born between 1945 and 1965. Routine screening for hepa- titis B is not recommended, although vaccination is recom- mended for those with HIV or with sexual risk factors.

Mental health providers can reduce disease transmis- sion in the SMI population by a combination of education on safe sex practices, treatment of substance use including injection drug use, robust infection control programs at mental health facilities, the facilitation of screening, and the provision of immunization for vaccine-preventable diseases.


Cancer is among the top ve leading causes of death in patients with SMI.1 An 11-year prospective study showed cancer as the second leading cause of mortality, especially lung cancer for men and breast cancer for women.56 A recent large study also found lung cancer death rates much higher in patients with schizophrenia and overall cancer rates high in middle-aged persons with schizophrenia compared to the rest of the population.57 is is, at least in part, attribut- able to disparities in cancer screening in mentally ill patients due to multiple barriers.58 A higher prevalence of risk behav- iors such as tobacco smoking in the SMI population is also likely to contribute to higher rates of cancers.

Educating consumers of mental health services and facilitating their access to appropriate preventive services can help reduce disparities in screening. Cancer screen- ing guidelines are published by the US Preventive Services Task Force (USPSTF) and other professional societies. e USPSTF guidelines, as well as those of some other organi- zations, are available free to the general public.59 It is to be noted that guidelines are evidence-based and thus change when new evidence emerges on the long-term bene ts and risks of screening, as well as the cost e ectiveness of testing. For example, previously, there was no routine screening rec- ommended for lung cancer detection. Now, the USPSTF recommends annual helical computerized tomography scanning for those with a 30-pack year smoking history and who either are current smokers or have quit less than 15 years ago. It also o en happens that di erent profes- sional societies disagree on recommendations. For instance, controversy is still raging over USPSTF recommendations in 2009 to start mammography at a later age of 50 years and at a lesser frequency of biennial. e USPSTF recommends

against prostate speci c antigen-based screening for pros- tate cancer whereas the American Urologic Society con- tinues to recommend shared decision-making between providers and patients on the utility of screening with pros- tate speci c antigen for men aged 55–69.60 Hence, it is use- ful for psychiatrists and other mental health professionals to keep abreast of major developments in cancer screening and, to the extent possible, be aware of current guidelines.

Reproductive Health

A complete discussion of clinical issues related to women’s health—speci cally, contraception, pregnancy, and post- partum care—in patients with mental illness is beyond the scope of this chapter. Readers are referred to a review of services and recommendations for women with schizo- phrenia who are of childbearing age.61 Although this review focuses on schizophrenia, the recommendations are appli- cable to all women with mental illness. e major recom- mendations are to (1) engage all women of childbearing age in discussions of sex, sexually transmitted disease, and con- traception; (2) carefully monitor patients during all stages of pregnancy within an appropriate level of care; (3) adjust psychotropic agents as indicated; and (4) address substance use issues early in the preconception period so that adequate treatment can be initiated to prevent use during pregnancy.



As discussed earlier, there is increasing awareness of clini- cal integration across services, and this has become a focus for several policy initiatives. e Institute of Medicine, in its proposed strategy to improve quality of care for people with mental illness, gave importance to greater clinical inte- gration among di erent service providers.62 e Agency for Healthcare Research and Quality (AHRQ) reviews di erent models of integrated care across both primary care and specialty settings.63 e President’s New Freedom Commission for Mental Health advocates for improved detection of mental health issues in primary care.64

A Bazelon Center report in 2004 examined four approaches that still remain salient7: (1) the embedding of primary care providers within public mental health pro- grams, (2) uni ed programs that o er mental health and physical health care through one administrative entity, (3) initiatives to improve collaboration between indepen- dent o ce-based primary care and public mental health,


and (4) colocation of behavioral health providers in pri- mary care o ces. e role of the consumer was highlighted, with a recommendation for providers to provide education and support so that individuals could take an active role in managing their health.

e Medical Director Council of NASMHPD devel- oped a “Four Quadrant Model” (Table 5.1) of service need, a population-based tool that has become the conceptual framework for many subsequent initiatives. e quadrants and populations are described as follows9:

I. Low to moderate risk/complexity for both behavioral and physical health issues

II. High behavioral health risk/complexity and low to moderate physical health risk/complexity

III. Low to moderate behavioral health risk/complexity and high physical health risk/complexity

IV. High risk and complexity in regard to both behavioral and physical health

Quadrants II and IV include individuals generally served within community mental health centers whose physical health needs have been challenging to address. Aspects of the chronic care model (see later discussion) are

incorporated in these blueprints for integrated care, with an emphasis placed on creating comprehensive programs that provide education, care coordination, and self-management tools in order to enhance outcomes. Individuals in quad- rants I and III are best served in the primary care setting.

Behavioral Health in Primary Care

Early models of integrated care, in which mental health providers are brought into medical settings, have been tested for depression, anxiety, and substance use disor- ders (SUDs). Most of these interventions have shown an improvement in symptom severity, treatment response, and remission, with the most robust results seen with depression treatment.63,65 A 2012 Cochrane review showed that, in addition to depression and anxiety out- comes, there is some evidence of improvement in mental health quality of life although less so for physical quality of life.66 However, there is promise for improvement in physical health indicators, as shown in some interven- tion studies.67 Many of these models utilized a depression care manager who was supervised by a psychiatrist and provided education, care management, and brief psycho- therapy and facilitated additional consultation by the


Quadrant I

(Ex. Mild depression with controlled diabetes)

Served in primary care clinics with psychiatric consultation if needed

Quadrant II

(Ex. Schizophrenia and controlled diabetes)

Served in specialty behavioral health centers with primary care collaboration

Also served in residential behavioral health agencies, emergency departments, inpatient behavioral health units

Quadrant III

(Ex. Moderate to severe depression and uncontrolled diabetes)

Served in primary or specialty medical clinics with psychiatric consultation and care manager as needed

Also served in emergency departments, inpatient medical units, and nursing homes

Quadrant IV

(Ex. Schizophrenia and uncontrolled diabetes)

Served in specialty behavioral health centers with primary and specialty care collaboration

Also served in residential behavioral health agencies, emergency departments, inpatient behavioral health units, inpatient medical units

Low Physical Health Complexity High

Adapted from National Council for Community Behavioral Health Care.9



High Behavioral Health Complexity Low

psychiatrist to the primary care physician for medication management.

e Improving Mood Promoting Access to Collaborative Treatment (IMPACT) model is one such example of collaborative care across multiple primary care practices.68 Patients requiring care beyond psychiatric con- sultation were referred to short- or long-term behavioral health specialty treatment. Hence, the elements of this col- laborative model are (1) systematic psychiatric assessment; (2) a nonphysician care manager to perform longitudinal symptom monitoring, treatment interventions, and care coordination; and (3) specialist-provided stepped-care recommendations.69 e TEAMcare model employing primary care provider consultants and nurse educators along with psychiatric consultants ensured improvement in medical disease targets.67 Examples of this collaborative care model are Depression Improvement Across Minnesota, O ering a New Direction (DIAMOND); the Mental Health Integration Program in Washington state; and large national health care organizations like Kaiser Permanente.

Skills required of psychiatrists and other mental health professionals who work in these settings are exibility, adaptability, ability to work in a team, availability for con- sultations outside of structured times, ability to appreciate cultural di erences in primary and behavioral health care environments, and an interest in public health. Mental health providers in these settings usually provide both informal and direct consultation, education of primary care providers, and leadership within the collaborative care team. Traditionally, training programs have focused on collaborative and direct consultative care in inpatient set- tings. Many of the learned skills are applicable to outpatient practice also, and there is increasing recognition that outpa- tient mental health care is an important part of consultative training.

Primary Care in Mental Health

e approach of integrating primary care in mental health settings is less well studied. However, some experimental models have shown promise. ese models spanned a con- tinuum of approaches with intermediate to high levels of involvement by primary care providers and regular contact between medical and mental health sta . ey showed improvement in quality of medical care and some evidence of improvement in health outcomes.5,63 Care management was speci cally tested as an approach in the Primary Care Access, Referral, and Evaluation (PCARE) trial. Care man- agers provided communication and advocacy with medical providers, health education, and support in overcoming

system-level fragmentation and barriers to primary medical care. ose people with SMI who had a care manager were more likely to have received preventive services and treat- ment, and have an established primary care provider.70

e SAMHSA has a Primary and Behavioral Health Care Integration (PBHCI) grants program that supports the inte- gration of primary care services into behavioral health treat- ment for adults with SMI. SAMHSA developed the PBHCI program to support the coordination and integration of pri- mary care services into publicly funded, community-based behavioral health settings with goals of improved access to primary care, improved prevention and early identi cation of physical illness, and increased availability of integrated care. More than 100 grantees have been funded so far in regions across the United States. Program characteristics of each grantee organization and speci cs of service integration vary considerably.71 Early reports from evaluation of grantee programsshowimprovedaccesstocarewithinorganizations that provide colocated care and demonstrate frequent com- munication between providers. ere is also some indica- tion that health outcomes, such as diabetes and BP control, improved in patients served in these integrated programs, although there was no reduction in the rates of obesity and tobacco use, which are markers of preventive care.72

Funding these integrated programs is challenging, espe- cially outside of an existing program such as the PBHCI. Many programs have been initiated by community mental health agencies, and they have partnered with local federally quali ed health centers (FQHC). e FQHCs are able to bill for primary care services at the prospective payment sys- tems rates. Some mental health systems have also taken steps to attain FQHC status because of the funding advantages it o ers for an integrated health system. A notable example is the Cherokee Health System in Tennessee. Some behavioral health organizations have set up their own primary care clinics outside of a grant program in response to medical need, but nancial sustainability is an ongoing issue in these settings.


Integration of care can occur across a spectrum from mini- mal collaboration between o -site practices to a completely merged primary and behavioral health practice.73 Here, we present an overview of the levels:

1. Coordinated care. Practices are at di erent sites, but there is sharing of information either periodically or driven by speci c clinical care issues.

2. Colocated care. Practices are in the same site, but funding is separate, records are usually separate,


treatment plans may be shared, and there is better communication between providers at the two practices.

3. Integrated care. Practices share the same space, providers communicate consistently at all levels, there is team- based resolution of systems issues, one treatment plan,
a blended culture of practices, and there may be shared resources and integrated funding (Table 5.2).


Successful integration involves screening for co-occurring conditions, determining the need for treatment of those conditions, implementing mechanisms for on-site treatment


or outside referral, arranging for e ective linkages between providers to coordinate care, and providing organizational support for collaboration.27

e Center for Advancing Integrated Mental Health Solutions at the University of Washington, a forerunner of the collaborative approach, lists the following core prin- ciples in integrating primary care and behavioral health74:

1. Patient-centered care. Team-based care; e ective collaboration between primary care and behavioral health providers.

2. Population-based care. Patients tracked in a registry so that outcomes can be measured for groups or populations.

3. Measurement-based treatment to target. Measurable treatment goals and outcomes de ned and tracked for each patient; treatments are actively changed until clinical goals are reached.

4. Evidence-based care. Treatments used are evidence-based.

5. Accountable care. Providers are accountable and reimbursed for quality of care, clinical outcomes, and patient satisfaction, not just the volume of care provided.
Regardless of the site of integration, the team-based

approach is emphasized in an integrated model. A team of behavioral health and primary care professionals with a shared vision and values should be developed. Once formed, there should be continual assessment of the functioning and goals of the team. Care delivered should be patient- centered and evidence-based, with patient outcomes mea- sured and monitored continually.75 e SAMHSA-HRSA center for integrated health solutions (CIHS) recently developed a set of core competencies relevant to working in diverse settings and integrating primary care into behav- ioral health. ey are also a resource for educators as they develop training programs on integrated care.76 e com- petencies are arranged into the following major categories within the context of an integrated health care team:

1. Interpersonal communication
2. Collaboration and teamwork
3. Screening and assessment
4. Care planning and care coordination 5. Intervention

6. Cultural competence and adaptation 7. Systems-oriented practice
8. Practice-based learning
9. Quality improvement informatics


Coordinated care (separate facilities)

Minimal collaboration

Basic collaboration at a distance

Colocated care (same facility)

Basic collaboration on-site

Close collaboration onsite with some system integration

Integrated care (shared space)

Close collaboration approaching an integrated practice

Full collaboration in a transformed/merged integrated practice


Communication occurs rarely and is driven by provider need

Providers view each other as resources and communicate periodically for speci c patient needs

Separate systems. More regular communication and more reliable referral process due to proximity. Treatment team is ill-de ned.

Some sharing of systems. In-person communication as needed and coordinated plans for di cult patients. Better sense of an integrated treatment team.

Frequent communication. Collaboration with desire to be a single care team. Regular team meetings to overcome barriers and in-depth under- standing of
roles and culture

Most systemic barriers are resolved. Collaboration driven by shared concept of single treatment team. Blended roles and cultures.


Adapted from Substance Abuse and Mental Health Services Administration- Health Resources and Services Administration Center for Integrated Health Solutions.73




e chronic care model serves as the foundation for the patient-centered medical home (PCMH) structure and concept. is model grew out of an awareness that primary care practice tends to be organized around acute care but must shi to a continuing care model. is model incor- porates six elements for improving the quality of care for chronic illness77,78:

1. Providing self-management skills to patients and their families

2. Redesigning care delivery systems

3. Linking patients to community resources for support in
illness management

4. Providing decision support to clinicians

5. Using computerized clinical information tools to
support adherence with treatment protocols and
monitoring health indicators

6. Aligning the health care organization’s structures and
values to support chronic care

A PCMH is a team-based model of care led by a primary care provider who provides continuous and coordinated care throughout a patient’s lifetime to maximize health outcomes. e core principles include a personal physi- cian for each patient, a physician-led practice team with responsibility for ongoing care across the patient’s life span, and care coordination across health systems and aligned payment methods. Family physician and pediatric groups initially proposed the characteristics of a PCMH.79 e health homes do not need to provide a full array of services themselves but must ensure availability of those services and coordinate care. e team at the medical home pro- vides care that is patient- and family-centered, comprehen- sive, continuous, accessible, and culturally competent. e concept of the medical home model is intended to improve health care by transforming how primary care is organized and delivered. A successful medical home requires a col- laborative relationship between primary care providers and specialists, including psychiatrists.

e Agency for Healthcare Research (AHRQ) de nes the components of a medical home.80 e National Committee for Quality Assurance (NCQA) uses this model to list the standards required for a health care

center to qualify as a medical home.81 Some of the core components are:

1. Comprehensive care. e care team is responsible for meeting the large majority of physical and mental health care needs including preventive, acute, and chronic care. e care team includes a physician provider, nurse, and health educator, among others.

2. Coordinated care. e team coordinates care across other elements such as specialty care, home health care, hospital-based care, and community supports.

3. Patient-centered. e team partners with patients and their families to develop a self-care plan and provide tools to manage their care. Patients needing additional care may be identi ed for proactive management.

4. Accessibility. e medical home is responsive to patient need and delivers culturally and linguistically appropriate services within convenient hours and options for a er-hours care.

5. Quality and safety. e medical home is committed to using evidence-based care, performance measurement, population health management, and patient satisfaction.

e medical home is conceptually aligned with inte- grated care. However, a primary care-based medical home may not be the best treatment setting for people with SMI, especially given that, for many of them, the only connec- tion with the health care system is at community mental health centers. ere is recognition of the need for a strong focus on integrating behavioral health care management into the PCMH.82–84 e National Council for Behavioral Health recommends that community mental health centers be de ned as medical homes for the SMI population. In a related development, the SAMHSA-HRSA center for inte- grated health solutions released guidelines on core clinical features of behavioral health homes (BHHs) for people with substance use and mental health conditions.85 e application of core principles of PCMH and the chronic care model and the structural frameworks to achieve this in BHHs are outlined in this document. Care management is an integral component of a BHH and combines the princi- ples of health homes in an integrated health delivery system.


e A ordable Care Act (ACA), passed in 2010, creates options for state Medicaid programs to provide health


homes for those with chronic medical and mental health conditions. ere is a nancial incentive for states as there is federal assistance for health home-related services. e ACA requires many of the services just discussed— comprehensive care plan for each patient, person-centered and evidence-based care, preventive services, linkages to community resources, care management, and care coordi- nation. States are instructed to address mental health and SUDs regardless of which chronic condition is selected as the primary focus. Individuals eligible for health home ser- vices must have either a serious and persistent mental health condition or two chronic conditions (or one condition with risk of developing another). Due to this strong empha- sis on mental health in the Medicaid health home, there is opportunity for behavioral health organizations to become health homes for the SMI population. e PCMH is the model for the Medicaid health home.

States are authorized to develop prospective payment mechanisms for health home services, and the payment is for a team and not an individual provider. e Centers for Medicaid and Medicare Services (CMS) provide incentives for states to implement health homes. Each state has ex- ibility in designing the payment structure. Initiatives that are under way to develop BHHs within community mental health centers in Connecticut are described next.

Behavioral Health Home Initiative in Connecticut

Connecticut’s Department of Mental Health and Addiction Services (DMHAS) has taken a strategic proactive approach to the development of BHHs for the Medicaid population with serious mental illnesses and co-occurring SUDs. In anticipation of a Medicaid State Plan Amendment (SPA) requesting federal funding for BHH services, $10 million in new state funding has been budgeted and a comprehen- sive planning process undertaken to build capacity among private nonpro t as well as state-operated community men- tal health centers to provide the comprehensive care man- agement, care coordination, and other services identi ed in Section 2703 of the ACA.86 Each community mental health center will serve as the BHH for eligible Medicaid enrollees in their designated catchment areas. To set the stage for the rollout of this initiative, the DMHAS has engaged the lead- ership of the community mental health centers in a series of collaborative planning and technical assistance discussions about the service delivery model, outcome goals, quality measures, eligibility, enrollment, sta ng, billing, provider standards, data collection and management, and ongoing learning supports for BHH sta .

e goals of Connecticut’s BHH initiative are:

1. Improve quality by reducing unnecessary hospital admissions and readmissions

2. Reduce substance use
3. Improve transitions of care
4. Increase the proportion of individuals with mental

illness who receive preventive care
5. Improve chronic care delivery for individuals with SMI 6. Increase person centeredness and satisfaction with care

7. Increase connection to recovery support services

DMHAS plans to utilize data from the Medicaid Management Information System (MMIS) and the ser- vices of an Administrative Services Organization (ASO) to improve coordination across the care continuum through use of a universal care plan and data sharing among BHH providers. The ASO will build and over- see an interoperable data system to support the provider network, oversee provider credentialing, provide train- ing and technical assistance, support an ongoing “learn- ing collaborative,” enroll and track service recipients, analyze and report on data collected, and support the building and processing of Medicaid claims for BHH services.

e scal model includes the following elements:

1. Services will be billed on a statewide per member per month rate.

2. Services will be billable if one or more BHH services are provided during the month.

3. All claims must be substantiated by appropriate clinical documentation in each individual’s service record.

4. CMS-approved Random Moment Time Studies will be conducted.

5. Providers will be paid by DMHAS with prospective quarterly contract distributions.

6. Funding from DMHAS will be based on expected enrollment at each community mental health center, based on Medicaid claims data from 2013 at the outset, as well as on a multidisciplinary sta ng model that includes licensed clinicians as well as peer recovery specialists.

As of this writing, the plan is to negotiate sta ng and funding with each community mental health center, allo- cate the dollars through the state’s administrative processes, and bring the BHH sta on board at each location such


that the capacity to provide services, track data, and gener- ate the Medicaid claims is in place when the Medicaid state plan amendment is approved.


is section describes an example of an integrated care clinic serving the primary care needs of patients at a mental health center. It illustrates the clinical, administrative, and nancial structures of this model along with the challenges of developing and sustaining such a clinic.


e Wellness Center (WC) at the Connecticut Mental Health Center (the CMHC) is a project formed in part- nership between the CMHC and the Cornell Scott-Hill Health Center (CS-HHC), an FQHC. e WC is one of the projects funded by the PBHCI program of SAMHSA. e CMHC is the community mental health center serv- ing the greater New Haven area, and it is operated as a col- laboration between the Yale Department of Psychiatry and Connecticut’s DMHAS. Approximately 5,000 patients with psychotic, a ective, anxiety, and SUDs are seen every year. Services include outpatient care, inpatient care, walk-in services, and community rehabilitation services such as sup- ported housing, supported employment, assertive commu- nity treatment, and jail diversion. Almost 70% of patients served are minority populations, and 36% of CMHC patients are uninsured. Prior to the recent SAMHSA fund- ing, on-site medical services were provided by the medical evaluation unit that cared mostly for inpatients and for urgent consultative medical needs of outpatients.

e CS-HHC is a federally quali ed community health center serving the New Haven population from 18 loca- tions and provides comprehensive primary and preventive care. Services include medical, dental, laboratory, nutrition, nursing, pharmacy, and behavioral health programs and programs for special populations such as homeless people and those with AIDS. e CS-HHC has a community- controlled board of directors. Approximately 79% of the population served by the center belongs to a minority group, and 24% are uninsured.

e WC located at CMHC is a clinic that provides on-site primary care services to the CMHC patient popu- lation. It is a colocated model of integrated care. e sta at the WC include (1) a nurse practitioner who provides medical care, educates patients on health care and chronic

disease management, and refers patients to specialty ser- vices as appropriate; (2) a nurse care manager who conducts intake assessments, assists in developing individualized wellness plans, provides health education, and coordinates with behavioral health providers and o -site specialty pro- viders; (3) a medical assistant who supports the clinical activities of the medical provider and nurse care manager; and (4) three peer health navigators who assist patients to enroll in primary care services, engage patients in self-care and healthy lifestyles, help patients with health literacy, provide practical assistance to keep medical appointments, and assist patients in navigating health services in the com- munity. One of the navigators is bilingual in English and Spanish. A sign language interpreter employed by CMHC is also available for patients with hearing disability. In addi- tion to sta described here, several other key clinical and administrative personnel in both organizations are respon- sible for overseeing daily clinical operations, and they meet regularly to solve systems based issues. e medical director is a physician dually trained in internal medicine and psy- chiatry who oversees clinical activities at the WC and serves as a liaison between the primary care team and the mental health professionals.


Patients are referred to the clinic by the outpatient behav- ioral health providers or they self-refer. Behavioral health providers routinely screen for health indicators such as engagement with a primary care provider, medical his- tory, tobacco and other substance use history, fasting blood sugar or HbA1c, fasting lipid pro le, BMI, and BP. When patients have medical needs that require specialty services, they are referred to community or hospital-based clin- ics that partner with CS-HHC. Patients can utilize phar- macy services on the main campus of CS-HHC, if needed. e CS-HHC maintains electronic medical records and CMHC maintains paper charts, but it is transitioning to electronic records as of this writing. For every patient seen at the clinic, consent is obtained for sharing medical infor- mation. e nurse care manager facilitates the transmittal of information from clinic visits to behavioral health pro- viders immediately a er each visit. e peer health naviga- tors identify high-risk patients and assist with collaborative treatment planning for those patients. Direct communica- tion between the behavioral health providers and primary care sta occurs based on need and allows for warm hand- o s when necessary. Patients are tracked in a registry that allows for population-based management as well as indi- vidualized health plans.



In addition to primary care services, the integrated pro- gram provides many health promotion services. e goals of these programs are to prevent development of medical conditions by risk modi cation and to e ectively manage existing chronic conditions. ese programs have targeted common conditions seen in the SMI population such as tobacco use and obesity that contribute to increased mor- bidity and mortality.

In addition to providing integrated care and wellness promotion activities for patients at the WC, the center has also begun a population-based program with a goal of improving the physical health of everyone in the center— both patients and sta . Based on the concept of primary prevention, this program attempts to provide multiple opportunities for all members of the CMHC community to live healthier lives. Activities such as smoking cessation programs and periodic health fairs have been well received. Recent activities have focused on providing opportunities to increase movement in daily life through the installa- tion of showers and lockers, an exercise room with 24-hour access, and attaining a bicycle-friendly business designa- tion; to improve the quality of food available through the colocation of a farmers’ market, a complete redesign of the inpatient and outpatient food services emphasizing local fresh food, guest chef demonstrations, and community gar- dening; and to reduce stress through free yoga and medita- tion sessions.

e CMHC has also been a smoke-free facility since 2008. Smoking cessation aids are o ered free of cost to patients. Psychiatrists are required to address smoking cessa- tion and document smoking status in their clinical reviews.

Challenges in an Integrated Clinic

Financial Sustainability

From the outset, a key strategic goal of the CMHC’s integrated clinic has been its long-term viability and sus- tainability. Addressing this goal requires a multifaceted approach to the separate but linked components of the initiative. ere is no single funding stream or reimburse- ment mechanism currently in place to support all the pieces of this collaborative endeavor. at said, the core clinical service provided by the on-site FQHC-operated primary clinic is the most straightforwardly sustainable compo- nent as long as the volume of clinic visits continues to be near or at capacity, the no-show rates remain at no more than 30%, and the payer mix remains heavily Medicaid and Medicaid/Medicare eligible. In other words, assuming a reasonably favorable payer mix and su cient volume, the

FQHC’s rate of reimbursement is su cient to support the direct service time of a practitioner teamed with a medical assistant. However, it is questionable whether the revenue will support clinic sta ng beyond these two positions, which means that other funding sources will be needed to continue paying for clerical/receptionist support, a full- time licensed practical nurse (LPN)/coordinator, and three peer health navigators. In the case of CMHC’s clinic, the decision was made from the outset to provide the clerical/ receptionist support on an in-kind basis. us, it would not be unreasonable to expect this to continue a er the SAMHSA grant support is gone. Unfortunately, under cur- rent Medicaid guidelines, most of what the LPN does is not reimbursable. e same is true for the peer health naviga- tors. But with the upcoming rollout of the BHH initiative in Connecticut, there may very well be an opportunity to keep these positions funded, albeit somewhat realigned to address the broader goals of the BHH. Given the critical importance of the primary care/behavioral health integra- tion, it will be a very high priority for CMHC’s leadership to identify resources (either new or reallocated) to continue to support as much of the sta ng as possible.

Any strategic sustainability e ort must also focus on aspects of the endeavor that extend outside the walls of the colocated primary care clinic. Most notably, it will be incumbent on leadership and the clinical and support sta at all levels within the CMHC to keep care coordination and the integration of health, wellness, and medical care issues into behavioral health service delivery at the forefront of clinical practice. is will require substantive and visible support from executive leadership, ongoing use of perti- nent data, continuous training and technical assistance, and focused supervision in clinical rounds, as well as on an indi- vidual basis. Such e orts will be an enormous undertaking. Fortunately, the BHH rollout will inject critical resources and provide further impetus for organization-wide integra- tion e orts well in advance of the end of the SAMHSA PBHCI grant.

Clinical Barriers

In addition to these administrative and nancial issues, there are challenges in implementing e ective clinical ser- vices. e clinic currently serves the primary care needs of a large volume of patients, but optimal care coordination is still a challenging goal to accomplish. e clinic’s LPN has a multitude of clinical and administrative tasks that leave less time for direct care coordination. Also, as in many inte- grated health settings, sta turnover rates are high. is is partly due to multitalented sta leaving for better opportu- nities and partly due to the cultural challenges of working


within an integrated setting. Another area of challenge is in the collection of data that track patient outcomes in real time. A web-based registry, which is an important tool for population-based chronic disease management, has not been readily available, and other less useful databases have had to su ce.

e biggest challenge is true clinical integration. Currently, there is frequent communication between the medical and behavioral health teams; however, treat- ment plans are still separate and unique to the teams. Communication is usually based on need and not routinely part of all patient encounters. Separate medical records make a truly shared care plan all the more challenging. Although the primary care sta are exible in their approach, it is still an ongoing task to educate them on the special needs of the SMI population. A fast-paced environment, in part driven by the nancial and clinical need to serve large numbers of patients, limits the amount of extra time that providers can spend in patient education.

Psychiatrists and other mental health professionals have also expressed a desire for better communication with the primary care team. Although the current model, with its on-site primary care provider, is perceived as being extremely useful, immediate and e ective communication is still a challenge with a single part-time mid-level pri- mary care provider. Mental health professionals also face some di culty adapting to the primary care culture and incorporating screening and referrals for medical condi- tions as a routine part of their practice. Also, the process of referral was considered cumbersome and an additional burden by mental health clinicians in the initial phases. is, however, was much less of a barrier than at many other sites because CMHC leadership and sta have been long aware of the medical needs of SMI patients. Another clinical challenge is coordinating specialist referrals because these are o -site. Although the health navigators assist with reminders and transportation, it is still a chal- lenge to maintain a high level of adherence. Also, mental health providers do not have direct communication with specialists, and any exchange of clinical information takes place mainly through the primary care provider.

Although the wellness clinic has placed signi cant emphasis on wellness initiatives, participation by patients in these activities still remains less than desired. At the end of the rst year of clinic operations, there were no signi cant improvements in rates of smoking cessation and weight loss. is is consistent with the experience of other PBHCI grantees. Many creative methods of engaging patients are continually being developed.


e wellness center is in the middle of the spectrum of integrated care, with colocation and coordination of ser- vices, but it is not a completely integrated practice. ere are many challenges in building a fully integrated prac- tice: (1) nancial, in the form of a need for integrated funding, a single billing structure, and long-term sustain- ability; (2) administrative, in the form of a need for a com- mon registration process and sharing and allocation of resources throughout the entire practice; (3) data sharing, in the form of a need for an integrated system for sharing medical information; (4) integrated treatment plans, in the form of a need to implement one evidence-based practice treatment plan across di erent disciplines; and (5) uni ed culture, in the form of a need to blend organizational roles and cultures among disciplines.

Within a colocated model, there must be regular com- munication between providers that is not driven simply by clinical need, but by a desire for improved sharing of clinical information between both sets of providers, a shared treat- ment plan, a system in which there is a seamless response to all health care needs, and a blended work culture.

For the wellness center to be transformed into a fully operational medical home, it will need to continue to develop along several lines. Team-based care will need to be re ned, including more frequent use of single plans of care, and coordination with outside entities must be streamlined. More challenging will be the adoption of shared electronic health records that can be accessed easily and that have the capacity to provide meaningful data to patients and providers to maximize population-based initiatives.87 e upcoming rollout of the BHH initiative in Connecticut will hopefully help surmount some, if not all, of these challenges.


e challenge in integrated care and any PCMH is for a health care organization to achieve the triple aim of improved population health care, improved health outcomes, and reduced costs. e literature on integrated care is still in its infancy, and the evidence for improved health care access and outcomes for people with SMI is still emerging. Also, nan- cial reimbursement models have to be continually redesigned before integrated care is sustainable in the long term.


In populations with chronic illness, outcomes improve with the use of care models that integrate clinical information,


evidence-based treatments, and proactive management of care. Health registries can be an e ective way of managing ill- ness and measuring outcomes. Integrated care delivery oper- ates on the principle that access to a uni ed and integrated source of care will result in improved health. Measuring outcomes in service delivery as well as health status in the target population is necessary to identify actionable targets. Population-based measurement and management of chronic health conditions are important for identifying determinants of health and wellness. Given the importance of continuous assessment of quality of care in an integrated practice, the SAMHSA calls for development of data registries to track primary care and behavioral health outcomes of participants in the PBHCI program. However, web-based registries to track health outcomes in real time are not yet widely avail- able, and this remains an area under development. Health homes also need to follow these evaluation metrics, and the CMS requires states to collect and report information on health home services delivery.


Integrated health care delivery systems are critical for the SMI population, given their poor health outcomes and increased mortality. ere are multiple reasons for poor health in this population, including poor access to quality care. Although many models for improving behavioral health in primary care settings have been tested, there are fewer evidence-based deliv- ery systems to improve the physical health of the SMI popu- lation. Emerging evidence for di erent models of integration shows promise for improving health outcomes for people with SMI. With the implementation of ACA, in many states, Medicaid health homes that incorporate the principles of a PCMH are becoming a viable nancial option. BHHs stim- ulated by the SAMHSA may emerge as a key service delivery model for state behavioral authorities and community behav- ioral health centers. Many national organizations and federal agencies are facilitating the shi to an integrated and chronic care management system of health care delivery. Psychiatrists and other mental health professionals can be at the forefront of this change. ey can be leaders in integrated care, both by providing high-quality clinical care and by designing service delivery systems in the era of health care reform.


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Donna LaPaglia, Brian Kiluk, Lisa Fucito, Jolomi Ikomi, Matthew Steinfeld, and Srinivas Muvvala


• Recovery from substance use disorders (SUDs) is possible and is de ned by individual progress.

• ere is no single best approach to recovery from SUDs; however, it must happen in the context of a person’s life.

• Addictions research shows promising interventions for the treatment of SUDs, and public psychiatry can help with the di cult task of system adoption.

• Public systems must make an “organizational diagnosis” to determine system strengths and weaknesses. Public systems need to make structural, policy, sta /training, and resource shi s to better care for the people they serve.


People who seek treatment for their substance use disorders (SUDs) in public psychiatry settings tend to present with complex medical and psychiatric comorbidities. As a result, treatment engagement and adherence may be challenging due to the chronic nature of these issues and the hurdles in navigating what are frequently complicated systems of care. When people do present for treatment, the public profes- sional is faced with the o en di cult diagnostic task of formulating a clinical picture from fragmented information and from o en murky clinical presentations complicated by numerous chronic health, psychiatric, and substance issues.

Although clinical formulation and treatment planning with this population is among the most challenging tasks for the public-sector professional, the authors suggest that the diagnosis and treatment of substance-using individuals occurs most e ciently in the context of interdisciplinary teams and can no longer occur in specialty addiction pro- grams alone. e authors advocate for the development of dually competent public service professionals through an integrated approach to the treatment of mental illness and

addiction that includes (1) an understanding of the neuro- biology of addiction and genetic factors, (2) an understand- ing of the environmental and comorbid factors of addiction, (3) strong assessment and diagnostic skills, (4) the abil- ity to assess and manage intoxication and withdrawal, (5) knowledge of local resources and their designated level of care, (6) knowledge of pharmacologic interventions for all substances including nicotine, (7) knowledge and skill in behavioral interventions for addictions, (8) an a priori understanding of systemic challenges and the ability to suc- cessfully navigate them, and (9) the need for participation in the research and implementation of new treatments. Systems of care bene t when high-quality research science and high-quality clinical practice inform and support each other and, in so doing, improve the care for the most chron- ically ill and vulnerable individuals served.

In this chapter, it is essential to carry forth the theme espoused by the textbook: that an essential role of the public professional is practicing without the “white coat.” e authors contend that nowhere is it more important to practice this way than when working with addictions and traversing the gap between traditional therapeutic methods


and the gathering of human data through the collection of urine, breath, and blood. e authors wholeheartedly agree that the public psychiatry professional must be comfort- able and uid in his or her approach and must, above all else, believe that therapeutic encounters happen beyond the clinic walls. In this way, the public psychiatry professional is poised to lead interdisciplinary professional teams in the practice of state-of-the-art care.

A nal theme of the chapter highlights the importance of leadership training for the public psychiatry professional. Given that many public psychiatry fellows advance into leadership positions, it is essential that fellows develop an advanced re ective capacity and prepare themselves for the di cult and emotionally stirring work of leading teams in this e ort. Curriculums need to expand to teach leadership theory that not only addresses knowledge of local, state, and federal systems; management skills; and the concept of community as treatment, but that also places value on fel- lows recognizing personal bias and attitudes and in devel- oping a leadership identity. ese curricula are delivered through the use of re ective writing, in class re ection exer- cises, and in peer interaction through the use of leadership cases. Public psychiatry can no longer a ord to thrust train- ees into leadership positions and hope for the best; rather, the eld needs to create space for the intentional practice of leadership within a complex system (see Chapter 18).


e 19th century saw the development of separate, pub- licly funded service systems in mental health and substance abuse, each with distinct care ideologies impacting service delivery. Unfortunately, most public behavioral health sys- tems continue to operate with separate arms for treating mental health and SUDs. What happens for people with co-occurring mental health and SUDs? Recent reports from the Substance Abuse and Mental Health Services Administration (SAMSHA) indicate that, although there is a high prevalence of people with co-occurring disorders (COD) in treatment settings, only 7% of this population receives treatment for both disorders.1,2 With increasing evi- dence supporting the e ectiveness of integrated treatments for persons with COD,3–5 professionals in public psychiatry must consider the factors that continue to impede optimal integration of care in public behavioral settings.

e most common factors accounting for this prac- tice gap include issues at the systems, programmatic, and workforce level. e large-scale structural impediments

include federal and state regulations around contracted ser- vices and funding streams.6 Di ering care ideologies, spe- ci cally around the treatment philosophy of mental health programs versus specialty substance abuse programs, also account for di culty in implementing an integrated treat- ment approach.7 e lack of trained and credentialed sta to carry out integrated treatment interventions,8 along with shi ing sta patterns due to high rates of sta turnover,9 also impede successful programmatic implementation.

At the public policy level, discussions are focused on ways to increase knowledge of addictions in professional mental health programs around the nation. e relative inattention to this issue stands in stark contrast to data on the high frequency with which people with addictions present to the mental health system. e consequences of this imbalance lead to underdiagnosis of SUDs or treat- ment by an untrained practitioner.8 Both practices are unacceptable, at the educational and at the individual practitioner level.


To develop a working knowledge of how to treat SUDs, it is necessary to understand the historical development of the current system. e mid 1700s saw the emergence of a public awareness of the damaging e ects of alcohol and intoxication. e rst classi cation of intoxication as an addictive disease requiring proper medical care was helped by the observations of physician Benjamin Rush. His early recordings of behavioral symptoms associated with drunk- enness led to his writing of “Inquiry into the E ects of Ardent Spirits on the Human Mind and Body,” the rst treatise on alcoholism. is work led to the “addiction dis- ease” concept, which is de ned by biologic predisposition, drug toxicity, pharmacologic tolerance, disease progression, craving, loss of volitional control of intake, and the patho- physiologic consequences of sustained alcohol and opiate ingestion10 and leads to the designation of the disease alcho- lismus chronicus.11

In 1830, the eld of addiction medicine emerged as a specialty, looking beyond the consequences of the addiction and focusing on the organic basis of “alcoholic behavior.” Inebriety became a central organizing principle and helped to de ne a movement of distinct treatment approaches based on the type of inebriety—alcohol, opiate, or cocaine. Several other important advances occurred during this time, among them the formation of the American Association for the Cure of Inebriety (AACI),12 texts on the nature of


addiction and treatment methods, and the development of terms describing the mental health consequences induced by prolonged alcohol use. Carl Wernicke and Sergei Korsako both wrote about psychosis—Wernicke wrote about a psychotic state brought on by prolonged alcohol use, and Korsako described an alcohol-induced psycho- sis that included hallucinations, memory impairment, and confusion.

Following this period in which work on the topic pro- liferated, the early 1900s saw the collapse of addiction treat- ment programs in the wake of the Great Depression and the beginning of prohibition laws. Patients su ering from addictive disorders were sent to the back wards of state psy- chiatric hospitals instead of to addiction treatment centers. is period also saw the o shoot creation of private hos- pitals designed to care for wealthy patients su ering from addictive disorders.

In addition to the loss of addiction-speci c program- ming, the passing of the 18th Amendment transferred responsibility for chronic alcoholism from physicians to the legal system. e Harrison Act (1914) took this idea one step further and threatened to punish physicians with loss of license or jail if they failed to steer patients toward rapid detox and abstinence.13 To make matters worse, in 1919, the American Medical Association (AMA) opposed the prac- tice of ambulatory treatments for narcotic maintenance. It was not until Charles Terry and Mildred Pellens wrote e Opium Problem (1928),14 which provided the stron- gest argument in favor of maintenance treatment options for patients su ering from opiate addiction, that the AMA reconsidered its position.14

In addition to medication-assisted treatments, the eld of addiction medicine made room for developing therapeutic approaches called fellowship models. Alcoholics Anonymous (AA) was one such program, founded in 1935 by Bill Wilson and Dr. Bob Smith. AA opened its doors to all those su ering from alcoholism regardless of socio- economic status, gender, age, or race. e only requirement of the participant was “an honest desire to stop drinking.”15

From roughly 1940 to 1960, the AA fellowship strengthened its advocacy for specialized medical treatment for their peers, which included medical detoxi cation and a ercare services necessary for continued support. Also helping to propel a rebirth of addiction-speci c services was a mid-twentieth-century reform that removed people with addictions from the penal system and reinstated their care with the medical community.

Other pivotal treatment services emerged during this time and still exist today: peer-run residential therapeu- tic communities, methadone maintenance programs, and

outpatient abstinence-based programs. One of the rst out- patient alcoholism clinics opened in Connecticut in 1968, as a freestanding satellite clinic of the Connecticut Mental Health Center, with a mission to treat addiction disorders in an ambulatory care setting.

In the 1970s, local, state, and federal systems partnered to improve communication, pool resources, and expand the scope and quality of the addiction service system. In addition, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA) were founded with a research mission that continues today: to understand and develop treatments to reduce the staggering social costs of addiction.


As this brief history suggests, the service system of addiction medicine is largely orthogonal to the mental health system; however, it is important to note the distinct and structural elements of addiction medicine in comparison to the sys- tem of mental health services presented in Chapter 2. Levels of care within addiction services include detoxi cation (ambulatory, inpatient), inpatient, residential (therapeutic communities, wilderness/holistic recovery programs), par- tial hospital (PHP), intensive outpatient (IOP), outpatient including opioid agonist maintenance programs, self-help groups (AA, NA, etc.), and sober housing (Oxford Houses, Recovery Houses). e interface between the addiction ser- vices listed here and mental health services remains limited and continues to present navigational challenges for both sta and patients.

A similarly challenging interface exists between addic- tion and medicine, speci cally in primary care where individuals with addiction frequently present with health issues. ese health-related encounters o er health care professionals the opportunity to intervene in the cycle of addiction. However, despite regular access to patients withaddiction,aservicegapexists:medicalsta arepoorly educated in addictive disorders, sta o en holds negative attitudes toward patients with addictions,16 and there is a lack of insurance coverage for the provision of addiction services (which is not seen with mental health or health- related issues).

e burgeoning eld of addiction medicine is mak- ing strides toward closing the gap between medicine and addiction. In 2007, addiction medicine established its own independent board, the American Board of Addiction Medicine (ABAM), to ensure quality training


and certi cation for physicians in the diagnosis and treat- ment of addictive disorders. A model of integration and inclusion, the ABAM board includes eight specialties cov- ering all aspects of addictions: emergency medicine, family medicine, internal medicine, obstetrics and g ynecolog y, pediatrics, preventive medicine, psychiatry, and surgery. With increased priority given to addictions in organized medicine, it appears that the discipline of addiction medi- cine is poised to help manage the increased need for medi- cally integrated addiction services under the A ordable Care Act (ACA).


Following this account of the historical evolution of addic- tion medicine, we now turn to understanding addictions at the individual and biological level. Drug addiction can be de ned as compulsive seeking and use of drugs despite severe negative consequences.17 is is brought about by various long-lasting changes induced in certain regions of an individual’s brain that makes them susceptible to com- pulsively seek and use the drug, to lose control of this use despite negative consequences, to have a negative emo- tional state in the absence of the drug, and to have cravings and urges to use the drug for prolonged periods despite abstinence.18,19

Multiple brain systems have been connected with the development of addictive disorders. ese include the dopaminergic, cannabinoid, opioid, GABAergic, seroto- nergic, cholinergic, glutamatergic, and neuromodulatory (via neuropeptide Y) systems. Various regions of the brain have been identi ed in which changes at the molecular and cellular level in uence and mediate addictive behaviors. Out of these, the most studied is the mesolimbic dopami- nergic system consisting of the dopamine neurons in the ventral tegmental area of the midbrain, which innervate the nucleus accumbens of the striatum and many forebrain regions including the hippocampus, amygdala, and prefron- tal cortex.17–19


Various genetic and environmental factors are believed to account for the individual variability found in becom- ing susceptible to drug addiction.18,19 Genetic factors can either be directly responsible for the development of addic- tive disorders or the development of personality traits leading to potential addictive behaviors.20 For example, a

well-documented example of genetic variations that may lead to the expression of addictive disorders in individu- als is the ALDH 2 gene variant, which is implicated in the production of an inactive aldehyde dehydrogenase enzyme. Individuals with a homozygous ALDH 2 gene are less likely to develop alcohol use disorders due to the occurrence of an alcohol–disul ram-like reaction resulting from acetalde- hyde accumulation.21

Genetic factors are also related to the expression of per- sonality traits in individuals more likely to develop drug and alcohol use disorders. Some individuals act more impul- sively than others and in an unplanned manner to satisfy a desire. DRD4 (dopamine receptor D4), DAT (dopamine transporter), TPH1 (tryptophan hydroxylase 1), SERT (serotonin transporter), MAOA (monoamine oxidase A), COMT (catechol-O-methyl transferase), and GABRA1, GAGRA6, GABRB1 (GABA receptors) are all gene vari- ants associated with this personality trait.20

Individuals who demonstrate excessive risk-taking behaviors do so when they undertake an act with uncertain or inherent negative consequences with little contingency planning; such people are associated with gene variants like DRD3 and DRD4.20

Additionally, a person’s low stress responsivity can pre- dispose him or her to express addictive disorders. Response to stress is modulated by the hypothalamic-pituitary-adrenal axis and can be a ected by gene variants like OPRM1 (mu opioid receptor) and COMT.20

Transcriptional and Epigenetic Mechanisms of Addiction

Although there is individual variability in the risk of developing addictive disorder due to heritability, stud- ies also have shown that individuals with lower genetic loading for addiction can develop an addictive disor- der with exposure to sufficiently high doses of drugs for a prolonged period of time. Drug-induced adapta- tions can be seen as “molecular or cellular memory” wherein nerve cells undergo changes due to prolonged exposure to drugs and respond differently to the same and/or different drugs and various other stimuli.18,19 Multiple mechanisms have been shown to change the transcriptional potential of genes. Proteins that bind to regulatory regions of genes, like ΔFOSB and cyclic AMP-responsive element-binding protein (CREB), have been shown to mediate the long-term effects of drug abuse on the brain.18,19 More recently, epigenetic mecha- nisms have been shown to alter gene expression without


directly changing the DNA sequence. Epigenetic mecha- nisms change the accessibility of genes by controlling the packaging of DNA within the cell nucleus.18,19 Various brain regions, such as the hippocampus, amygdala, and prefrontal cortex, are affected by these changes; this results in abnormalities in the traditional memory cir- cuits and leads to clinical outcomes like drug cravings and relapse. Addicts can remain at risk for relapse to drug use despite prolonged abstinence, thus suggesting that drugs can induce lasting changes in the brain.18,19 Thus, our improved understanding of the biology of addic- tion challenges the age-old assumptions about addiction being a “moral problem” or a “weakness.”


The development of addictive disorders may also be the result of environmental factors, which may be familial or nonfamilial. Environmental factors influence the addictive behaviors in interaction with the individual’s genetic composition. Availability of drugs and alcohol at home or within a community or society, age of first use, peer influence, a history of trauma, and other soci- etal factors like lack of structure and increased antiso- cial behavior, may all contribute to the development of addictive behaviors.


The prevalence of all psychiatric disorders is higher in substance-abusing patients than in the general populations. Furthermore, 50–60% of patients with an addictive disorder also have a coexisting psychiat- ric diagnosis. This may be either a primary psychiat- ric disorder occurring independently of the addictive disorder or a substance-induced psychiatric disorder. Mood disorders, anxiety disorders, psychotic disorders, antisocial personality disorder, and attention deficit hyperactivity disorder are the most common psychi- atric problems seen among patients with SUDs. For these reasons, integrated care of both the substance use and the psychiatric disorder should be the standard approach in such cases.


Best practice in the treatment of SUDs starts with a thor- ough biopsychosocial assessment.22 Box 6.1 includes key

factors to include in the diagnostic interview with the goal of producing a comprehensive, person-centered care plan and treatment disposition.


Motivation for change: Assess patient’s current motivation/ readiness for treatment and for changing his or her substance use behavior. Treatment approaches that address motivation may be useful (e.g., Motivational Enhancement erapy, Contingency Management, etc.).

Psychiatric comorbidity: Assess whether there are comorbid psychiatric and/or personality disorders along with a SUD. Consider a treatment approach that addresses the mul- tiple conditions (e.g., combination of pharmacotherapy and psychotherapy).

Medical: Assess for direct toxic e ects of the substance on the body (such as alcohol on the liver) or e ects due to proce- dures associated with drug use (needle sharing among heroin users leading to hepatitis C, HIV, etc.).

Social history: Assess for level of academic achievement, extent of social support, quality of relationships, employment, stabil- ity of living arrangements, and current or past legal issues.

Family history: Assess for SUDs across family systems; use genograms to depict patterns of use across biological and/or environmental family systems.

Trauma history: Assess if substance abuse began or increased following a period of abuse or a traumatic event, and assess the presence of symptoms indicating post-traumatic stress disor- der (PTSD). If so, consider an approach that addresses both conditions simultaneously (e.g., Seeking Safety). Consider patient’s strengths and resilience in surviving the trauma.

Cultural context: Assess the cultural context of the substance- using behaviors. Consider whether substance use is part of or vio- lates a patient’s cultural, spiritual, or religious values and practices. Consider enlisting members of the patient’s faith community.

Substance use history: Assess patient’s history of substance use beyond “drug of choice” including the range of psychoac- tive substances; assess the amount and frequency of use and period of longest “clean time.” Consider what resources the patient utilized during periods of abstinence.

Coping skills: Assess if the patient has a limited repertoire of coping strategies. A treatment approach that incorpo- rates skills training for avoiding substance use may be useful (e.g., Cognitive-Behavioral erapy [CBT], 12-Step Facilitation, etc.).






Sedatives/ hypnotics


Supportive management. Hydrate,
parenteral high dose thiamine (protective against Wernicke’s encephalopathy), folic acid, prevent aspiration; manage hypothermia, hypoglycemia and metabolic derangement.

Naloxone (IM/SC) administration, intubation and ventilation may be required. Due to short half-life of naloxone, continuous monitoring of respiratory rate is required and recurrent naloxone administration might be needed.

Supportive management. Flumazenil maybe used, but with caution, due to precipitation of benzodiazepine withdrawal.


Benzodiazepines are the treatment of choice. Can be given as xed dose and tapered or by symptom triggered approach with use of CIWAr protocol. Other drugs, which have been used for detoxi cation, are carbamazepine, valproic acid, propranolol, phenothiazines, gabapentin, and barbiturates, none of which has shown superior e cacy over benzodiazepines.

Detoxi cation
1. Non opiate detox: Symptomatic treatment with clonidine,

ibuprofen, benzodiazepines, anti-diarrheal medications.
2. Opiate detox: methadone or buprenorphine initiation and taper.

Benzodiazepine taper is the treatment of choice. For ease and smoothness of detoxi cation, longer acting benzodiazepines like diazepam and clonazepam are preferred to shorter acting such as alprazolam. Anticonvulsants have also been used for benzodiazepine detoxi cation, but benzodiazepines remain the main stay of treatment.

Inpatient psychiatric care is required for patients at risk to self or others or for those who are considerably disabled to the point where they are unable to take care of themselves. Medically supervised detoxi cation in an inpatient setting is required for patients using considerable amounts of alco- hol, benzodiazepines, or opiates and for patients for whom prior withdrawals evidenced conditions like delirium tre- mens or seizures. Residential treatment may be indicated if there is chronic daily use, severe medical comorbidity, lack of stable housing, lack of supportive social networks, high- risk surroundings, long history of addiction, or poor treat- ment adherence.

e length of stay varies greatly among treatment pro- grams, with some lasting as long as a year. For patients who may bene t from a greater number of clinical contacts than weekly outpatient treatments, partial hospital programs and intensive outpatient programs are available. Partial hospital programs run every day for a total of 20 or more hours, and the clinical programming is highly structured. is level of care is a step down from 24-hour care.

Intensive outpatient programs involve 3 or more days per week for 3 or more hours per day with a varied length of treatment, generally between 6 and 12 weeks. Patients who bene t from this level of care are those with a high risk of relapse. ey require more structure and need more intensive counseling. ey may have minimal support net- works within the community, and some of the focus should be on connecting the patient to supportive clinicians and networks of care within the community prior to being stepped down to a lower level of care. All other clients who



It is essential to be able to assess the signs and symptoms of intoxication and withdrawal and to be able to provide the necessary treatment interventions to prevent the poten- tially lethal consequences that accompany them. Table 6.1 outlines the management of intoxication and withdrawal for alcohol, opiates, and sedatives/hypnotics.23 Medications are not required to manage intoxication or withdrawal from other classes of substances unless there are acute psychiatric symptoms or complicating medical problems.


An appropriate level of care needs to be determined to for- mulate a treatment plan and to initiate appropriate psycho- pharmacological and psychotherapeutic interventions. ese treatment recommendations are best made within the context of an interdisciplinary team with input from various providers creating the most comprehensive disposition/plan. e two parts to this process involve decision-making about the level of care or treatment (e.g., inpatient vs. outpatient vs. residen- tial, etc.) and conducting a safe hand-o to the next provider. Factors for consideration are patients’ goals (total abstinence vs. reduction), safety (is the patient at risk to self or others?), level of impairment (is the patient able to carry out regular activities of daily living or are they gravely disabled as a result of chronic substance use?), and amount of substance use (heavy, daily ingestion of a substances is best treated at a higher level of care with the availability of medical services).


are usually motivated with some history of treatment adher- ence, a binge pattern of SUD, or some community supports (family, engaged in 12-step program, case management) can generally be treated in less frequent forms of outpatient care.


Pharmacological intervention for SUDs, heavily in uenced by disposition and patient placement, can be e ective in helping patients achieve abstinence and/or experience symptom reduction. e treatment of a comorbid mental illness is vital in this pursuit, as research has shown that doing so will result in more favorable outcomes as well as improved treatment adherence. Moreover, relapse rates are reduced when comorbid symptoms such as depression, anxiety, and insomnia are addressed. Detoxi cation alone is not necessarily adequate to promote abstinence or maintain decreased drug use and recovery.

Appropriate pharmacologic and psychotherapeutic treatment options must be discussed with patients and put into e ect. Treatment of opiate use disorders with agonist medications like methadone or buprenorphine have been shown to be highly e ective. Prolonged treatment with the optimum daily dosage of these medications is more e ective than short-term tapers or detoxi cation treatments. Agonist maintenance treatment has been shown to be particularly e ective in reducing craving, decreasing illicit opiate use and opiate overdoses, improving treatment adherence, and decreasing HIV risk and criminal behaviors in this popu- lation.24 Opiate antagonists like naltrexone have also been used for maintenance treatment of opiate use disorders. Oral naltrexone is shown to be less e cacious due to poor compliance and retention rates. Extended-release naltrex- one (depot) injection when combined with psychosocial interventions has been shown to improve the adherence and retention rates thereby improving the e cacy in pre- venting relapse on opiates.25

e US Food and Drug Administration (FDA) has approved disul ram, naltrexone (oral and XR formulation), and acamprosate for the maintenance treatment of alcohol use disorders. When prescribing disul ram, patients should be extensively counseled about disul ram–alcohol reac- tions, and they must avoid all products that contain alco- hol. Oral naltrexone is most e cacious in reducing heavy drinking days. Both Acamprosate and Naltrexone have been shown to prevent relapse to drinking.26 Topiramate, an anticonvulsant, has been shown to have e cacy in treat- ment of alcohol use disorders, and, although it is not FDA approved, NIAA clinical guidelines have encouraged the use of this medication.26

Other non-FDA approved medications for the treat- ment of alcohol use disorders, which have shown some e cacy, are gabapentin, ondansetron, baclofen, and var- enicline.26–30 FDA-approved medications for tobacco use disorders are nicotine replacement, varenicline, and bupro- pion.31 Despite extensive clinical research, there still remains no approved maintenance medication for the treatment of stimulants (cocaine, amphetamines, methamphetamines), cannabis, hallucinogens, and inhalants.


Cigarette smoking is frequently overlooked when perform- ing substance abuse assessments and neglected in the course of treating SUDs. Yet cigarette smoking is the leading pre- ventable cause of morbidity and mortality in the United States.32,33 An estimated one-third of adults with mental illness smoke cigarettes compared to less than one- h of adults without mental illness.32–34 Among individuals with SUDs, smoking prevalence exceeds 70%.33 Smokers with psychiatric disorders are less likely to initiate and maintain smoking abstinence,32,33 which contributes to the high pre- mature mortality rates in this population.32,34 For these rea- sons, there is an urgent need for primary and mental health providers to screen mentally ill patients for tobacco use and provide cessation assistance.32,33,35

e Tobacco Use and Dependence Clinical Practice Guidelines outline a treatment model with ve major components (i.e., the 5A’s; see Table 6.2).33 Clinicians are advised to assess tobacco use for every patient, to encourage those who use tobacco to quit, to assess interest in quitting, to assist by providing counseling and pharmacotherapy, and to arrange follow-up to promote abstinence. Patients who receive this model of support are more likely to initiate and maintain abstinence compared to patients whose quit attempts are not supported.33 In typical clinical practice, only the rst two steps are implemented or the rst two along with a referral for treatment (i.e., telephone quit-line or tobacco treatment specialist). Evidence-based treatment, however, dictates active clinician involvement through repeated assessments of tobacco use and the ongoing provi- sion of counseling and pharmacotherapy.

Evidence-based behavioral and pharmacological inter- ventions are e ective for smokers with psychiatric dis- orders.33 Moreover, there is little evidence that smoking cessation interferes with recovery from other SUDs.33 In fact, a meta-analysis of smoking cessation interventions pro- vided to patients in current addiction treatment or recovery




Ask about tobacco use Advise to quit

Assess willingness to make a quit attempt

Assist in quit attempt

Identify and document tobacco use status for every patient at every visit. Provide clear, strong, and personalized advice to every tobacco user to quit.

Determine if the tobacco user is willing to make a quit attempt at this time.

For the patient willing to make a quit attempt, provide assistance.

• Recommend evidence-based medications and explain how they increase quitting success and reduce
withdrawal symptoms.

• Help patient develop a quit plan using the STAR algorithm (Set a quit date ideally within 2 weeks, Tell
others and request support, Anticipate challenges, Remove tobacco products from the environment)

• Provide information about smoking and successful quitting and practical counseling (problem
solving/skills training) focused on recognizing, avoiding, and coping with triggers to use and

• O er intratreatment social support (encouragement about patient and quitting, communicate caring
and concern)

• Provide supplementary materials (e.g., self-help information) and encourage the use of additional
resources (e.g., state quitlines, online resources such as
For patients unwilling to quit, initiate motivational interventions to increase the likelihood of future quit
attempts; encourage patient to consider reduction as a starting point.

• Motivational interviewing/motivational enhancement therapy

• Use the “ ve Rs”
• Discuss:

• Reasons to quit that are personally relevant

• Risks of continued smoking

• Rewards for quitting

• Roadblocks to successful quitting

• Repeat counseling at subsequent clinic visits
Recommend smoking reduction and use of nicotine replacement therapies.

For patients willing to make a quit attempt, arrange follow-up contacts to prevent relapse. For patients unwilling to quit at this time, repeat assessment of tobacco use and advice to quit at subsequent visits.

Arrange follow-up


Adapted from Tobacco Use Clinical Practice Guidelines33 and Fiore and Baker.35


“Roger” is a middle-aged male with a history of alcohol dependence and depression. He presents for outpatient substance abuse treatment following inpatient treatment. He reports smoking a pack of cigarettes per day but states that he is unwilling to quit smoking at this time largely due to concerns that he will not be able to manage his other problems without smoking. He has chronic pain and peripheral arterial disease (PAD) that contributes to his distress. e patient states that pain is a trigger for both depression and alcohol use. How would you address smoking with this patient?

We would advise the use of motivational interviewing techniques or the “5A’s”; see Table 6.2) with this patient at each visit to help move him toward smoking behavior change. In particular, it would be important to help the patient understand the cycle of smoking, PAD, pain, and alcohol use/depression. In his case, smoking cessation would have a major impact on his chronic medical condition, would reduce his pain, and, consequently, reduce his relapse risk for both Axis I disorders. By the same token, the clinician should also focus on building the patient’s coping skills so that he feels better equipped to handle other problems without smoking. If the patient is willing to consider smoking reduction as an initial option, he should be encouraged to do so and provided with nicotine replacement therapy following the standard dose schedule (i.e., usually up to 3 months).35 If the patient becomes willing to make a quit, the clinician should follow the “Assist” and “Arrange” steps outlined in Table 6.2. We would also recommend combination nicotine replacement therapy for this patient (i.e., nicotine patch plus a short-acting form of nicotine replacement) because it is e ective for smokers with high nicotine dependence levels and depressive symptoms and safe for smokers with a history of alcohol.35

showed that smoking interventions were associated with a 25% increased likelihood of long-term abstinence from alcohol and illicit drugs.36 Clinicians may also wish to pro- vide smoking cessation treatment when SUD symptoms are not severe (see Box 6.2).33


e SAMHSA lists 69 di erent evidenced-based interven- tions for the treatment of SUDs on their National Registry of Evidenced-based Programs and Practices (NREPP;www. Some interventions have been found e ective for treating a range of populations (e.g., ages, gender, races/ethnicities), substances (e.g., alcohol, drugs, tobacco), and settings (e.g., inpatient, outpatient, residen- tial, etc.), whereas others are targeted to a speci c popula- tion. Here, we review some of the behavioral therapies with the most empirical support for the treatment of primary substance use and for co-occurring mental health and sub- stance use (in alphabetical order), including a brief descrip- tion of their underlying theory, key strategies for facilitating change in behavior, and typical delivery format, as well as references to treatment manuals and further informational resources.

Behavioral Couples erapy (BCT) for alcohol and drug use disorders is an approach that combines cognitive- behavioral methods for the treatment of substance use and BCT for distressed relationships.37–39 It is grounded in the assumption that substance use is maintained in part by interactions between the substance user and partner and is changed most e ectively by teaching both partners coping skills and improving the couple’s interactions. Key strategies include development of a daily sobriety contract, completion of a decisional balance related to substance use, functional analysis to identify patterns and key triggers to substance use, teaching coping skills to the substance user and partner, and enhancement of positive exchanges between the partners. Typical course of treatment is 12– 24 sessions (90 minutes each) on an outpatient basis, with both partners present for all sessions.

Cognitive-Behavioral erapy (CBT) for substance abuse is based on social learning theory, such that alcohol and drug use are deemed learned behaviors (i.e., through modeling; operant and classical conditioning).40–42 Providers help individuals recognize, avoid, and cope with triggers for alcohol/drug use by performing a functional analysis for identifying the patterns of substance use with respect to the triggers, thoughts/feelings, behaviors, and

positive and negative consequences; coping skills training; and practice of coping skills outside of sessions through speci ed assignments. A typical format is generally 12–16 weeks and can be individual or group-based.

e Community Reinforcement Approach (CRA) and the Community Reinforcement Approach And Family Training (CRAFT) in treating substance abuse are based on principles of operant conditioning, with an underly- ing philosophy that in order to overcome substance use, a person’s life must be rearranged so that abstinence is more rewarding than continued substance use.43,44 Key strategies involve functional analysis of substance use, sobriety sam- pling, CRA treatment plan with happiness scale, behavioral skills training, job skills training, social and recreational counseling, relapse prevention, relationship counseling, and the inclusion of concerned family members to change the home environment to reward behaviors that promote sobriety and withhold rewards when drug/alcohol use occurs. e typical format for CRAFT is generally 12–24 weeks of individual treatment (with the addition of signi – cant others).45

Contingency Management (CM) is an approach to treating substance abuse based on principles of behavioral modi cation, particularly operant conditioning, such that behaviors are reinforced by their consequences.46–49 Key strategies involve the identi cation of a speci c behavior to change (e.g., drug/alcohol use, treatment attendance, etc.), use of objective methods to verify desired behavior (e.g., urine testing), and providing incentives whenever the desired behavior has occurred (e.g., vouchers or cash, on- site prizes, clinic privileges, etc.). A typical format has a cli- ent monitored 2–3 times per week for 12–24 weeks.

Mindful-Based Relapse Prevention (MBRP) is an approach to treating substance abuse that integrates mind- fulness practices and cognitive-behavioral relapse preven- tion; a mind–body approach for recognizing innate healing abilities coupled with awareness of triggers; and the teach- ing of coping skills.50,51 Key strategies involve guided medi- tation, recognizing thoughts and emotions in relation to triggers, integrating mindfulness practices in daily routine, learning an awareness and acceptance of cravings/urges, and practicing skills in high-risk situations. Typical format is generally group-based for 8 weeks, with 2-hour sessions.

Motivational Interviewing (MI)/Motivational Enhan- cement erapy (MET) is an approach to treating sub- stance abuse that is grounded in humanistic psychology and that employs an empathic, client-centered, nonjudg- mental although directive style of interacting with people to assist individuals to move toward change.52,53 Key strat- egies involve using open-ended questions, a rmations,


re ections, summaries, and importance/con dence rulers; learning decisional balance; rolling with resistance; express- ing empathy; developing discrepancy; and supporting self- e cacy. Typical format is a brief intervention (fewer than eight sessions) and is commonly deployed in individual or group settings.

Twelve-Step Facilitation (TSF) is an approach to treat- ing substance abuse that assumes that addiction is a pro- gressive disease of mind, body, and spirit for which the only e ective remedy is abstinence from all mood-altering substances (i.e., the disease model).54 Key strategies involve encouraging attendance and engagement in AA/Narcotics Anonymous (NA) meetings; providing education about the 12 steps; giving feedback on negative consequences from substance use to facilitate acceptance of the problem; education on the process of denial; examination of “stink- ing thinking”; and identi cation of “people, places, things” as triggers to substance use. e typical format is 12 sessions of individual-based treatment and includes encouragement for the patient to attend 12-step meetings, undertake “spon- sorship” from an individual with more “clean time” that the person seeking treatment, and undertake “step-work.”

Supported employment and supported education can be integrated into standard treatment settings or be included as one of many “wraparound services”; these e orts seek to improve individual functioning and facilitate job acquisi- tion.55–57 Key strategies include (1) providing information about the job market, about the skills and experience nec- essary to obtain work, and about the bene ts and stressors inherent in each job; (2) helping the client develop a realis- tic understanding of his or her vocational skill set; (3) teach- ing problem solving and coping skills; (4) helping the client to develop motivation for job seeking; and (5) aiding the client in obtaining the proper entitlements, educational services (GED), certi cates, or skills training necessary to pursue employment (case management).58


ere are several approaches with signi cant research sup- port for treating adolescent substance use by including fam- ily members in the intervention. ese interventions can be relatively brief (e.g., 8–12 sessions) or more extensive (20+ sessions) depending on the severity of the problem and are generally exible so that they can be adapted to a broad range of service settings (e.g., mental health clin- ics, drug abuse treatment programs, etc.) and treatment modalities (e.g., outpatient intervention, continuing care service to residential treatment, etc.). Some examples of

family-focused approaches include Family Behavior erapy (FBT),59, 60 Brief Strategic Family erapy (BSFT), and Multidimensional Family erapy (MDFT), to name a few.


Integrated Dual Disorders Treatment (IDDT)61 is a treat- ment model based on the integration of treatment services for individuals with co-occurring SUDs and mental illness. Treatment is provided in a single facility, by the same team, with no time limit or number of sessions attached to the care. Key elements include stage-wise interventions, moti- vational interventions, substance abuse counseling (relapse prevention), supported employment, and outreach. Seeking Safety62 is a present-focused treatment for individuals with a history of trauma and substance abuse. It includes 25 top- ics that are evenly divided among cognitive, behavioral, and interpersonal domains, with each addressing a safe coping skill relevant to both PTSD and substance abuse. e treat- ment can be provided in individual or group format, with male and female clients, and in a variety of settings (e.g., out- patient, inpatient, residential). Dialectical Behavior erapy (DBT) is a well-established treatment for individuals with severe psychosocial disorders (including suicidality) and has been adapted for those with co-occurring substance abuse.63 DBT is a cognitive-behavioral treatment approach combined with acceptance-based strategies, with an empha- sis on dialectical processes. It is a comprehensive program typically conducted in outpatient settings and includes four treatment modalities: individual therapy, group skills train- ing, telephone consultation, and therapy for the therapist.


Although there is now ample evidence showing the e cacy of a range of treatments in their ability to increase treat- ment retention and to reduce the harmful e ects of sub- stance abuse, the question of how to know which validated intervention will have optimal e ect for a given patient is one of the ongoing challenges faced by clinicians providing community-based mental health care in the course of their daily practice.

e most substantive research to date attempting to match patient characteristics with a psychotherapeutic modality best suited to treat their symptomatic presen- tations has underscored the real complexity involved in choosing an evidence-based therapy to treat addictive


disorders64,65; the successful selection of treatment modality is as much an art as it is a science. Adding to the complex- ity of treatment selection is the fact that SUDs (along with certain paraphilias) are the only disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM 5) that are, generally speaking, illegal. is requires the clinician to decide whether a patient is disclosing the totality of his use history and to consider the extent to which real and per- ceived legal consequences stemming from such disclosure may lead to underreporting the severity of his addiction. Gathering collateral information through family members and signi cant others, as well as through urine toxicol- ogy analysis and an assessment of blood alcohol content, are vital in having a clear diagnostic picture with which to choose an appropriate level of care.


Despite the strong empirical evidence supporting the thera- pies described herein for the treatment of addictions, their overall e ect is relatively modest. For instance, reviews of treatments for alcohol use (including more than 8,000 peo- ple) have indicated that only about one-third of alcohol- dependent individuals remained abstinent during the initial 12-month period following treatment.66 Although this is a comparatively positive outcome, it suggests that a large per- centage of individuals do not respond to treatment. us, the future of addiction research may be viewed with a goal of maximizing treatment e ects so that they are applicable to the broader population. To maximize treatment e ects, we must rst understand how they work and for whom and under what conditions they work best. is has been a high priority in the eld of addiction research for the past decade and will likely continue as new approaches, such as those described in this section, are integrated into future research designs.


Although randomized controlled trials can demonstrate that a speci c treatment led to or caused change in a given outcome variable (e.g., decreased substance use), showing that a treatment causes change does not in itself explain how this change occurred.67 e “how” is explained through the identi cation of the speci c “mechanisms of behavior change,” which are the processes or events that are respon- sible for the change (i.e., the reasons that change occurred or how change came about).68,69 erefore, to improve

treatment outcomes for larger percentages of individuals seeking treatment, the speci c mechanisms need to be iden- ti ed so that future treatments can be adapted for certain individuals based on a better understanding of how and for whom that treatment works.

Emerging research has seen the incorporation of neu- roscience into the study of how addiction treatments may work, with neuroimaging being one such approach that has tremendous promise for furthering our understanding of addictions. Neuroimaging methodology includes structural brain imaging using magnetic resonance imaging (MRI) to measure the volume and shape of speci c brain regions, positron emission tomography (PET) for measuring brain activation and metabolic activity, and functional MRI (fMRI) for measuring brain activity during experimental manipulation of speci c cognitive processes.70,71 ese tools have been used to examine both predictors of relapse to alcohol or drugs, as well as changes in the underlying neural circuitry following treatment—valuable information that can be used to design more e ective behavioral and phar- macological treatments.72 For instance, incorporating f MRI can be useful for identifying speci c neural mechanisms of treatments for addiction, which can then shed light on new targets to enhance and individualize addiction treatments, as well as move toward potential biomarkers of treatment response.

Along the lines of individualizing addiction treatment, information on gene expression or proteins has become more prevalent in treatment research studies, with a goal of someday using genetic information to tailor decisions about which pharmacologic treatment (and potentially which psychotherapeutic treatment) or what dose of a medica- tion is most appropriate for a given individual.73 ere are several examples of early successes with this approach in other areas of medicine, such as tests of genetic variation used clinically to predict response to medications for breast cancer74 or to guide clinical decisions regarding the use of antipsychotics.75

Although, in the aggregate, the corpus of addiction research is still in its infancy, studies have supported the premise that genetic di erences may predict treatment out- comes from pharmacologic76 and psychosocial treatments.77 Moreover, future research that integrates genomic and neu- roimaging methods may lead to a greater understanding of the links among genetic variation, brain-based phenotypes, and treatment outcome, which may in turn lead to signi – cant improvements in treatment outcomes.73

Technology-based interventions provide another fruit- ful area for future addiction research as the rapid growth of technology and the omnipresent use of the Internet and


mobile devices o er a potential way to reach patients who have traditionally been resistant to engage in traditional treatment settings. Several technology-based interventions have been developed based on existing evidenced-based treatments, such as CBT, CRA, MET and other brief inter- ventions, and CM.78–84

Of note, several of these technology-based interventions are being implemented in public-sector programs. Such novel ways of delivering evidenced-based treatments may be particularly bene cial for the future of addiction treat- ment because the implementation of the ACA is likely to result in larger numbers of individuals attempting to access treatment, which may overwhelm the current resources available.

us, the future of addiction research will likely focus on attempting to develop a better understanding of how our current evidenced-based treatments work, providing them across a range of service platforms, and, in so doing, o ering these treatments to larger populations of individu- als and incorporating new methods into public-sector pro- grams to increase access for diverse populations.


For decades, addiction treatment services have operated without knowing—beyond anecdotal evidence—whether the treatments provided were e ective and, if so, in what ways. Under the pressure of health care reform, managed care companies began to force programs and providers to justify clinical decision-making, collect treatment out- comes, and survey consumers regarding satisfaction. In an era of increased program accountability, local, state, and federal agencies now require programs to collect data in order to maintain funding.

With an increasing emphasis on treatment e cacy and outcomes, state departments, like the Department of Mental Health and Addiction Services (DMHAS) in Connecticut, are designing elaborate real-time data collection systems that record program statistics like admissions, discharges, client demographics, insurance information, and drug of choice. ese data are used to inform programming deci- sions on the state level and to petition federal agencies for resources and support when needed.

At the national level, the National Survey of Substance Abuse Treatment Services (N-SSATS) gathers program data by level of care and compares states on a series of treatment outcomes. is annual survey goes out to program directors,

and the data are published online and in a comprehensive book of provider information. ese types of comparative data are used to spark discussion about national trends and for program and policy development.


Local addiction treatment services can seek accreditation in an e ort to increase patient safety and improve patient outcomes. Program accreditation ensures that standards of patient care are met and that de cits or gaps in treat- ment are identi ed and addressed. Examples of health care accreditation bodies include the Joint Commission on Hospital Accreditation (JCAHO), the Commission on Accreditation of Rehabilitation Facilities (CARF), and the Council on Accreditation for Children and Family Services (COA). With program accreditation as the gold standard, the 2006 N-SSATS reported that less than 50% of the nation’s addiction treatment facilities were accredited.85

Accredited and publicly funded programs in an era of sta ng shortages, scarce resources, and the increasing cost of medications experience pressure to continually improve services. e Network for the Improvement of Addiction Treatment (NIATX), a national collaborative endeavor for programs to share resources, advocates for improving care through the use of short-cycle process improvements, a tech- nique borrowed from the eld of engineering. Trying small changes in short study cycles helps achieve relatively cost- free, quick-change practice improvements. e approach allows health care professionals to continually test and revise procedures in an e ort to improve operations. e approach also helps build team moral, increases employee satisfaction, and enhances patient care.


e passage of the Mental Health Parity and Addiction Equity Act in 2008 achieved equality among all medical bene ts for behavioral health disorders including depres- sion, anxiety, psychotic spectrum illnesses, and SUDs. Additionally, “the passage of the ACA in 2010 has the potential to profoundly a ect the integration of the deliv- ery of mental health and addiction care.”86

In line with Mental Health Parity and the ACA, SAMHSA published the Treatment Improvement Protocol 42, which puts forth a “vision of fully integrated treat- ment.”87 Despite the compelling evidence base supporting integrated treatment for patients with comorbid addiction


and other mental illnesses, care is still fragmented and in short supply. “In the United States, treatment for most mental illnesses is provided by psychiatrists or primary care physicians. In contrast, care for addiction is provided almost exclusively at specialty treatment centers by indi- viduals of various disciplines, o en with little input from physicians.”88

Traditional mental health and addiction treatments have not adequately addressed these co-occurring disorders due to multiple challenges with training, program structure, and other systemic disconnects. Minko (1989) was one of the rst to propose an integrated model of addiction treat- ment.89 He set forth the design for treating co-occurring addiction and psychosis on an inpatient unit. His approach sought to help psychiatric clinicians by introducing them to 12-step philosophy while familiarizing addiction clinicians with the use of psychiatric medications. is dual training approach seeks to develop competencies in both mental health and addiction service professionals, but there is still a long way to go toward systems integration between mental health and addictions.


e authors contend that best practice in public psychia- try requires a push toward true dual competence, as seen in the strides made by medicine and addiction (discussed in the chapter introduction) and requires all clinical sta to become skilled in the assessment and treatment of SUDs—more speci cally, evidence-based treatments such as motivational enhancement therapy, relapse preven- tion (cognitive-behavioral therapy), and 12-step facilita- tion. In addition, the public-sector professional should be well-versed in integrated treatments including psycho- pharmacology, medical care, and empirically validated psychotherapies.90 Miller and Brown advocate for an integration of:

alcohol/drug problems in the core course work in psychopathology, assessment, and treatment . . . and need to be encouraged and expected from the beginning to think of substance abuse as a neces- sary and vital problem area to be included within their range of their professional competence, just as is the case for depression, anxiety disorders, and psychoses.91:1275

Integrated training programs should be the goal for medical educators. Perhaps the most crucial educational

element, beyond broadening a collective treatment mind- set of “whom” or “what” to treat, is to instill in students an openness, an optimism, and the desire to carry hope for patients with mental health and SUDs who are struggling to live healthier lives. It is essential, also, to focus educa- tional e orts on developing re ective leaders within our public psychiatry settings.


Public psychiatry has seen a shi in its emphasis from institution-based care to the community-as-treatment con- text, requiring the practitioner to take o the white coat and put on whatever hat is required. Public psychiatry calls for a compassionate human stance to the work, one in which respect and common sense prevail over traditional, rigid frames for providing care. At the same time, the eld must welcome proven science into our treatment settings and actively integrate those interventions when applicable. Finally, in the authors’ collective experience, leadership development of the public professional is critically essential to the health and viability of a public system poised to e ec- tively treat mental health and SUDs.


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Joanne DeSanto Iennaco, Jacob Kraemer Tebes, and Selby C. Jacobs


Public health concepts o er a lens for public psychiatry that focuses on the importance of understanding population needs and the determinants of mental health problems and of planning for prevention, resource development, and service allocation in public psychiatry.

• Attention to population-based mental health needs has resulted in the evolution of care from primarily institution-based to community-based services for those with mental illness.

• Major epidemiologic studies such as the Epidemiologic Catchment Area (ECA) survey and National Comorbidity Survey (NCS) o er information about the characteristics and determinants of mental disorders. ey provide a signal for problems requiring intervention and a foundation for better understanding how to promote mental health and prevent mental illness.

• Understanding the risks associated with outcomes such as psychiatric morbidity, mortality, and disability allows practitioners to focus on the priority needs for service delivery.

• Unique models for prevention such as the relationship between the Connecticut Mental Health Center (CMHC) and e Consultation Center (TCC) provide a model for research, service, and improvement e orts in care delivery to individuals with mental illness.


One of the hallmarks of public psychiatry is the integration of clinical practice with epidemiologic, public health, and system perspectives. ese perspectives o er a way of “see- ing” clinical problems in a broader context. ey enable the public psychiatry professional to understand the context of psychiatric disorders and practice, as well as set priorities for both clinical and preventive interventions and resource allocation.

Consideration of psychiatric public health is timely. Tragic events and public health problems in American soci- ety make education about public health in psychiatry of utmost importance. Public health perspectives contributed conspicuously to the community mental health movement at the dawn of the modern era of public psychiatry in 1963. Many factors contributed to the loss of that perspective over

time; it is important to return to the knowledge and prac- tice of psychiatric public health and integrate it into public- sector practice. Doing so will be critical in addressing the challenges of isolated young adults falling into psychosis and suicide and of military veterans with post-traumatic stress disorder. Public health strategies and the public sys- tem of care will help shi the focus of psychiatric practice to wellness and prevention by using population perspectives and to early intervention by bringing clinical perspectives to bear on the earliest stages of illness.

Population-focused psychiatric practice broadens the clinical lens from a focus on caring only for individuals with already present mental illness. Understanding the broader roots of illness provides a ready basis for iden- tifying interventions that can ameliorate the e ects of adversity. For example, considering activities that promote mental health or prevent mental illness includes engaging


in planning, implementation, and evaluation of disaster preparedness. Such interventions may prevent the onset or lessen the severity of illness as a consequence of natural or man-made disasters. e population-focused practice frame also includes interventions for those with existing mental illness to prevent the negative consequences of chronic conditions, thus limiting disability and the e ects of physical comorbidities. With a broader focus, many pre- ventive activities impacting individuals across a continuum of health and illness are addressed. A population focus also leads to more comprehensive planning of services in public psychiatry.

is chapter includes epidemiologic and public health facts; it also illustrates how using epidemiologic data and “public health thinking” can inform public psychiatry and enhance its practice.



e American Public Health Association de nes public health as “the practice of preventing disease and promot- ing good health within groups of people from small com- munities to entire countries.”1 To assess the health status of small and large populations, public health professionals use epidemiologic and other research strategies (surveillance) to understand the health concerns of speci c groups. is de nition de nes a domain of professional practice, which involves an interdisciplinary group of professionals inter- ested in protecting and promoting health.


According to the World Health Organization (WHO), mental health is “a state of well-being in which every indi- vidual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruit- fully, and is able to make a contribution to his or her com- munity.”2 Mental health, de ned in relation to behavioral disorders, is an extension of the de nition of public health in so far as it uses the same epidemiologic and surveillance strategies. Importantly, mental health is broader in scope, including social, behavioral, economic, and physical fac- tors. e term “mental health” also is sometimes used as a reference to community services, and it connotes a spec- trum of preventive, health-promoting, clinical, and reha- bilitative services in the community. “Behavioral health” is a contemporary term used to emphasize that both mental

illnesses and substance use disorders (SUDs) are within the domain of public psychiatry, which is de ned in Chapter 1.


American psychiatry has a long history, starting with the mental hygiene movement in the early 20th century, of incorporating public health perspectives into psychiatric practice, or at least into the public sector of practice. In 1955, a study of treatment for individuals with mental ill- ness was commissioned by President Dwight D. Eisenhower and led to publication of the report “Joint Commission on Mental Illness and Health: Action for Mental Health” in 1961.3 is report ultimately ushered in a transformation of mental health care.4 Propelled by this report, the modern era of public psychiatry opened when Congress enacted the Community Mental Health Act in 1963, which promoted construction of community-based centers for treatment and research to better understand mental illness.5 e fed- erally initiated community mental health movement, which spawned community psychiatry as a specialty of psychiatric practice, was predicated on public health concepts of early intervention, treatment in the community close to home, and continuity of care.6 Based on public health concepts of primary, secondary, and tertiary prevention, the services o ered by the Community Mental Health Centers Act included early identi cation of disease, prevention through outreach in the community to low-income and under- served populations, and action on social stresses and other environmental determinants using interdisciplinary teams to deliver care. is act spurred deinstitutionalization and initiated the delivery of public mental health care on a local level, thus improving access to care.6 is presented unique opportunities to develop and fund community mental health centers based on interdisciplinary collaboration.

e emergence of community and social psychia- try, community psychology, public health nursing, and community-based social work, as well as growth in the eld of public health to include a behavioral health focus, are examples of this in uence.7 Interdisciplinary collabo- ration was focal in the development of systems of care for those with mental health challenges.8 One such community mental health center was the Connecticut Mental Health Center (CMHC) in New Haven. ere, the preventive programs that originated in this period as part of general services were consolidated later into a center for preven- tion ( e Consultation Center [TCC]), which is described


later in this chapter as one example of how preventive ser- vices can be integrated into clinical practice and education. During the 1980s, the integration of psychiatric pub-

lic health into the practice of public psychiatry waned as federal and state governments focused on community- based services and rehabilitation for chronically ill people.9 Psychiatric epidemiology and prevention pursued more independent development as investigators carried out major epidemiologic surveys such as the Epidemiological Catchment Area (ECA) study10 and the National Comorbidity Study (NCS),11 which provided a foundation for descriptive epidemiology. Prevention specialists con- tinue to develop the theory and science of interventions, culminating in the Institute of Medicine (IOM) report on levels of prevention.12

In place of the federally driven community mental health movement, other professional, social, economic, and political forces shaped the public arena of psychiatry. Developments during these years contributed to outreach and psychosocial rehabilitation services in the commu- nity as an alternative to hospitalization, thereby reducing the disability resulting from institutionalization. Yet this determined focus was practically exclusive of anything else. Initiative for the development of community services shi ed to state governments from the federal level, which contin- ued its attenuated support through block grants. e rise of managed care and the shi to shortened hospital stays using payment based on diagnostic related groupings (DRGs) resulted in the downsizing of hospital systems and further movement of care from inpatient settings to community- based ambulatory services. Because care was constrained in hospitals and expanding rapidly in the community, it was di cult for communities with limited resources to respond to the needs of people discharged with serious and persis- tent mental illness.

Transinstitutionalization was a consequence; individu- als with mental illness wound up in other institutions for problems associated with chronic mental illness and sub- stance abuse problems. For example, with the development of Medicaid coverage, individuals were moved from state mental hospitals to nursing homes starting in 1965. Soon, the mentally ill represented 44% of residents, resulting in one form of transinstitutionalization.13:10 Also, there was an increasing rate of incarceration of the mentally ill in pris- ons. Steadman found that patient history of incarceration for drug-related o enses increased from 12.6% in 1968 to 27.6% in 1978,14 likely due to increased access to substances in community-based life and limited access to community- based treatment. In addition, during this same period, drug sentencing laws were tightened, thus leading to higher rates

of incarceration (from 501,886 to 1,587,791 between 1980 and 1995).15

In the early 1990s, the balance of spending for mental health care nally tipped to greater funding for community care as opposed to state institutions.13:1 Patients residing in state public mental institutions decreased from 559,000 to 154,000 from 1955 to 1980 and to 71,619 by 1994.13:5 E orts to provide care in the community were directed to both those with mental illness and those with intellectual disability. It is estimated that more than 764,000 people with SMI were living successfully in the community who would otherwise have su ered institutionalization had the changes in care never been undertaken.15

A public health perspective was largely lost until a Clinton White House conference in 1996 served as a pre- lude to a 1999 Report on Mental Health by the US Surgeon General. is public health report was the rst of its kind to document the mental health of the American popula- tion and note substantial progress in establishing the e – cacy of psychiatric treatments.16 It highlighted the idea of “burden of disease,” as introduced in the Global Burden of Disease study,17 which also introduced a new metric—the Disability Adjusted Life Year (DALY) based on indirect assessments of disability combined with mortality data. Analyses of burden of disease established a high priority for mental health in mainstream public health.17 It also under- lined the need for new ways of thinking about recovery. e Surgeon General’s report also advocated for better integra- tion between mental health and general health care.16

Two years later, in 2001, the Surgeon General issued a call to action to reduce suicides, thereby providing the rst national public health message on a major source of mor- tality from psychiatric disorders.18 In another report that same year, the Surgeon General directed attention to dis- parities in health care outcomes for members of minority populations.19 is report reinforced a call for culturally competent care from an earlier report to address the social factors that interfered with access to care and increased morbidity and mortality from psychiatric disorders (see Chapter 14).16 ese three reports taken together set a new course for psychiatric public health and set the stage for the New Freedom Commission (NFC) Report of 2003.20 While de ning a new public health agenda, the Surgeon General set the stage for streaming psychiatry into medi- cine. As the Surgeon General said in his introduction to the report, “there is no health without mental health.”

In 2003, on the heels of the Surgeon General’s report, the NFC noted that American society invested inadequately in programs and services at the front end of the trajectory of psychiatric illness; in contrast, enormous resources were


committed to tertiary care of disabled individuals with seri- ous mental illnesses (SMI) and addictions. e NFC report recommended more focus on the early stages of illness. As part of its call for a transformation of the American men- tal health system, the NFC underlined psychiatric public health as an important arena for development in public psychiatry. Speci cally, the NFC report recommended in its fourth goal that mental health screening be improved to enable timely clinical assessment (early detection) and refer- ral to continuing services if necessary to prevent chronicity. e commission intended that screening, in collaboration with primary care, become common practice. e NFC report emphasized not only early intervention but also prevention, health promotion, contingency planning for threats to the public health (such as disasters or epidem- ics), categorical programs for groups at high risk for bur- den of disease or documented as having disparate clinical outcomes, and health education. In these ways, the NFC brought modern public psychiatry full circle, back to the public health principles that guided it in its early stages of development starting in 1963.

In 2006, echoing the recommendations of the NFC, the National Institute of Mental Health (NIMH) published a report that characterized the burden of psychiatric disease on the American population as “one of the greatest public health challenges in contemporary medicine.”21,22 is arti- cle emphasized that psychiatry, in particular, faced major public health challenges, and it created a context for their solution as part of mainstream medicine. Also, 3 years later, the head of the federal Center for Mental Health Services (CMHS) highlighted the importance in the 21st century of public health in public psychiatry.23 In her discussion, she described prevention, early intervention, attention to social variables (such as disparities in outcomes for high- risk groups), and the need to focus not only on disease but also on wellness and resilience.

We now come full circle, back to a systems-level per- spective. Having furthered the science of psychiatry by identifying important brain pathways, genetic in uences, and the role of personality characteristics in individuals, we can now broaden our focus to the role of these factors in the larger scope of a population-based understanding of psychiatric disorders.24 e series of reports just described suggest areas for future research focus related to social determinants that in uence health promotion, disease prevention, and intervention and that have the potential to further the evolution of public psychiatry. e policy developments in public psychiatry provide an enormous agenda for the eld as it moves forward into the next decade of evolution.


Psychiatric epidemiology uses public health methods to provide a description of and investigate the characteristics and determinants of mental health problems and psychi- atric disorders in population groups. It also evaluates the e ectiveness of health services (health services research is considered in more depth in Chapter 17). Arguably, public health data serve an essential signal function in American psychiatry, monitoring progress in service development and forecasting problems needing correction. Several examples come to mind. e concept of burden of disease and data from the Global Burden of Disease study demonstrated the high burden of psychiatric disorders among all diseases and placed psychiatric disorders squarely on the agenda for state, federal, and international program initiatives.17 e Report on Mental Health by the Surgeon General provided evidence that the mental health system was in shambles and set the stage for the NFC, which articulated a trans- formation agenda in mental health. Data from a report by the National Association of State Mental Health Program Directors (NASMHPD) on a shortened life expectancy of 25 years for individuals with SMI demanded a response from psychiatry and primary care.25 Large-scale studies by services researchers exposed the misleading claims of large pharmaceutical companies that were marketing new gen- erations of antipsychotic drugs at very high cost.26 Finally, public health data on persistently high morbidity rates cre- ated the framework for a NIMH report calling for new directions in psychiatric research using “research domain criteria” as the dependent variable.27

Psychiatric epidemiology supports a population per- spective on psychiatric disorders that complements a clini- cal focus on individuals. To grasp the mental health of the community, it is essential periodically to step back from case-by-case experience and consider the needs of and ser- vices for the whole population. A population approach considers groups of people rather than individuals. It is another way of “seeing”; for example, epidemiology tells us that the majority of people who are mentally ill do not seek or receive treatment. How do we understand that fact and incorporate the untreated person into a comprehensive pic- ture of the disorder and need for services? And, although psychotic disorders may be the most conspicuous men- tal disorders in a community, they are not the most com- monly occurring (incidence), nor the most disabling, given available evidence on the prevalence and burden of mental disease.



Died 49%

Discharge to Community 27%


Institutionalized 25%

In Institution 38%

Outside Institution 11%

Figure 7.1 Mitchell Longitudinal Study of Institutionalized Patient Disposition (1858–70)

Epidemiologic analyses o er information about disease incidence, prevalence, and trajectory including recurrence, recovery, and comorbidity. is information is useful in a variety of ways, including in identifying risk factors impor- tant for universal prevention, in identifying high-risk groups to target with preventive interventions, and in plan- ning for the needs of those with severe and persistent mental illness. For example, one of the earliest reports of psychiat- ric epidemiology that focused on psychiatric service deliv- ery outcomes was an 1877 report of treatment at an asylum between 1858 and 1870 by Mitchell.28 e author found that of nearly 1,100 individuals admitted over 12 years, 25% were still living in an asylum, 38% had died in the asylum, 11% had died outside the asylum, and 27% were living outside the asylum at the end of 1870 (Figure 7.1).29 Of those living in the community, 9% continued to have a mental disorder, and 18% were identi ed as living “in a state of sanity.”29:26 Based on this report, attention to the causes of mortality and the need for community-based ser- vices for this cohort are highlighted.

Epidemiologic methods provide information on the e ects of childhood experiences on later risk and help clini- cians identify those at high risk and plan interventions to prevent future morbidity. For example, in a cohort study following children from birth to age 42 in the United Kingdom, Morgan et al. found relationships with parents in childhood predict later mental health problems: up to 24% of the studied population reported aspects of a poor rela- tionship, resulting in a 20–80% higher risk of adult mental illness.30:1714 ese results suggest great value in wellness and health promotion strategies focused on improving parent– child relationships.

Other longitudinal studies o er psychiatry a perspective on how to intervene to prevent future morbidity. In a 24- year study, Reef et al. found speci c trajectories from type of child externalizing behavior to greater risk of adult dis- order as de ned by the Diagnostic and Statistical Manual of

Mental Disorders (DSM IV).31 Children with externalizing behaviors were more likely to have substance dependence or disruptive disorders in adulthood; in addition, those with status violations (run-aways, swearing, truancy, substance abuse) were more likely to have a mood or anxiety disor- der as an adult.31:1238 Results from similar studies o er use of population-based information to inform clinical practice and planning for interventions to prevent future onset and management of psychiatric disorders.

Given the di erences inherent in clinical and popula- tion perspectives on physical and mental health, there are models speci c to public health that aid public psychiatry in planning for and delivery of services. ese include the Levels of Prevention model, the Matrix of Intervention in Public Health model, and the Mental Health Intervention Spectrum (IOM). Each model will be brie y introduced and illustrated here.



Modern public psychiatry incorporated an early framework for understanding prevention, the levels of prevention, which called attention to three types of prevention: primary, sec- ondary, and tertiary.32 ese ideas still o er a useful frame- work for planning and implementing a range of preventive interventions. Primary prevention is the actual prevention of disease or disorder. Vaccinations are a good example. In the absence of known etiology, primary prevention of psy- chiatric disorders remains a future goal for public psychia- try. Secondary prevention is the reduction in morbidity from disease or disorder, usually achieved via early intervention when symptoms respond best to treatment. Tertiary preven- tion is the prevention of disability associated with disease or burden of disease. All three types of prevention are discussed

N = 1,100 admissions


Mental Disorder 9%

No Mental Disorder 18%

here. e levels of prevention from primary to secondary to tertiary focus on the state of health or disease present, and it can be di cult to determine the point at which the disease state is present or absent. Many diseases (e.g., hypertension or depression) have a continuum of symptom severity rather than categorical thresholds that indicate a change to a dis- ease state. Given the di culty identifying the exact onset of mental disorders, another approach is to classify the focus of preventive intervention, which also expands the frame of targets for prevention.


is approach was rst identi ed by Gordon33 in regards to prevention of physical illness, and it identi es targets as universal, targeted, or selective and indicated.12,34 e Matrix focuses on the groups of individuals involved, the costs, and the proportion of the population expected to bene t from preventive interventions.34,35 Universal pre- vention refers to interventions provided to all individuals regardless of the presence of disorder. An example is educa- tion for all students in a school setting regarding substance abuse, mental health, or health-compromising behaviors.36 Other examples include bullying prevention programs and social skills training in schools.37 e intent of universal- level intervention is to either prevent problems or pro- mote competency and impact as much as 80–90% of the population.35:183 A smaller group, 5–15%, might bene t from selective or targeted preventive interventions, which are

focused on those who are at risk for the onset of a disor- der.35:183 For example, children with substance-abusing par- ents are at higher risk for substance use and abuse and may bene t from education about this condition and supports to resist invitations for substance abuse. Indicated preven- tive interventions are for individuals with a risk factor or abnormality that constitutes an early sign of the potential for development of a disorder.12 For example, adolescents who have experimented with substances but are not yet actively dependent may be o ered a substance abuse pro- gram designed to intervene to prevent further substance use. Another example is to have a home health visitor engage new mothers to prevent postnatal depression.38 e use of levels of prevention (primary, secondary, tertiary) helps in conceptualizing when in the course of illness an intervention might be used, whereas levels of preventive intervention from universal to indicated identify the pop- ulation focus for interventions. An example of a Matrix of Intervention for Suicide Prevention is provided later in the discussion of mental health outcomes (Table 7.1).

Recent conceptual frameworks have begun to empha- size health promotion along with prevention in public psychiatry, a development that was anticipated in the land- mark IOM report.12 Reducing risks alone may be insu – cient for preventing a disorder unless combined with the promotion of protective factors, such as the skills, compe- tencies, and supports that are critical in fostering resilience to adversity.39 us, both prevention and health promotion approaches function as essential tools for achieving health and well-being.40



e intervention is designed to a ect everyone in a de ned population.


e intervention is designed especially for certain subgroups at particular risk for suicide.


e intervention is designed for speci c individuals who, on examina- tion, have a risk factor or condition that puts them at very high risk.


Incorporate depression screening into all primary care practice

Improve the screening and treatment of depression in the elderly in primary care practices

Implement cognitive- behavioral therapy immedi- ately a er patients have been evaluated in an emergency department following a sui- cide attempt


Promote safe storage of re- arms and ammunition

Package drugs in blister packs

Reduce access to the means for self-harm in jails and prisons

Teach caregivers to remove rearms and old medicines from the home before hospi- talized suicidal patients are discharged


Teach con ict resolution skills to elementary school children

Provide programs that improve early parent–child relationships

Develop programs to reduce despair and provide opportuni- ties; increase protective factors for high-risk populations, such as Native American youth

Develop and promote honorable pathways for law enforcement o cers to receive treatment for mental and SUDs and return to full duty without prejudice



e IOM refers to a “mental health intervention spec- trum” that ranges from prevention to treatment and maintenance for mental disorders.12:23 Prevention in this spectrum refers only to preventive intervention before onset of a disorder. Treatment refers to both case identi- cation (screening) and standard treatment of disorders, including interventions to reduce the risk of comorbid disorders occurring. Maintenance refers to interventions over time delivered to those with persistent or prolonged disorders, in whom interventions focus on relapse preven- tion and rehabilitation.12:24 In the area of children’s men- tal health, Weisz et al. identi ed the importance of the addition of health promotion and positive development as a population-level focus on enhancing strengths and reducing the probability of later problems.41:632 Finally, in recent years, the SAMHSA has fully incorporated health promotion into the Mental Health Intervention Spectrum.42

Future approaches to prevention programs involve the use of technology in disseminating information as well as in providing screening and in understanding group-level behavior using methods such as social network analysis.43 Dynamics of interaction, such as peer relationships and norms within a work or school group, can be better under- stood using methods like social network analysis to de ne the setting or group-level variables of importance to behav- ior change or disorder prevention.43


Having provided an introduction to both epidemiology and prevention, the discussion now returns to descriptive epidemiology to review three types of outcome from men- tal illnesses and SUDs. ese are morbidity, mortality, and disability or burden of disease. All of them have implications for contemporary practice in public psychiatry.

Morbidity refers to the occurrence of illness and is docu- mented by means of descriptive, diagnostic criteria provided in criteria sets such as the DSM 5.44 e mortality from psy- chiatric disorders comes from suicide and premature deaths from diabetes, hypertension, and vascular disease in people with SMI. Burden of disease is a term that refers to the high rate of disability associated with psychiatric disorders. e discussions presented here of each outcome o ers examples of interventions that might address them.


Psychiatric disorders occur universally. In the past 30 years, the ECA and the NCS have described the prevalence of the major psychiatric disorders in American society.11,45,46 e burden of disease from psychiatric disorders in American society clearly ranks among the leading causes of disability. e prevalence and disability rates are general facts that are useful background when engaging a new population or community, sizing up its special mental health needs (if any), and deciding how to allocate clinical attention.

Schizophrenia (prevalence: 1.1%), among the most conspicuous of disorders by virtue of its bizarre symptoms, although disabling, is not the most common.45 Anxiety dis- orders (prevalence 18.1%) and a ective disorders (preva- lence 9.5%) are the most common disorders, but they tend to be less persistent and disabling.45 SUDs (past-year preva- lence of 3.8% and lifetime prevalence of 14.6%) are very common and can be acute or chronic and very disabling when addiction occurs.45,47,48 e total prevalence of psychi- atric disorders in American society is 46.4%. Comorbidity is common: 27.7% of those with a disorder have two or more disorders.47 Only 40–60% of cases of psychiatric disorder are treated.49 Of course, the proportion treated increases with the severity of illness (e.g., schizophrenia is more likely to require treatment vs. anxiety disorders). is chapter will not review the descriptive epidemiology of psychiatric dis- orders further because those data are readily accessible for clinical or evaluative purposes.

An important question that is repeatedly raised relates to the risk of aggression or violence in individuals with mental disorders (see Chapter 8). ere is evidence to support the idea that individuals with mental illness are actually more likely to be victims of violence than perpetrators.50 A recent analysis of information from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) found that violence was associated with SMI only if sub- stance use was involved.51 However, this nding was called into question by Van Dorn et al. who point out that the use of lifetime diagnosis of mental illness is not focused enough to address the causal relationship of diagnosis to violent events.52:488 In their analysis, diagnosis in the past year was used to evaluate risk of recent violence, and they found a higher risk in those with SMI (Relative Risk [RR] = 3.49); those with comorbid substance use had even higher risk (RR = 11.45), whereas those with substance use alone also had a signi cantly higher risk of violence (RR = 3.29).52:490–491 Finally, those with SMI and adverse childhood events (e.g., child abuse or neglect) had more than three times


the risk for violent behavior than those with SMI and no adverse childhood events.52:492–493


Mortality associated with psychiatric disorders manifests in two ways: suicide and premature mortality among people with SMI. e mechanisms of death for both are indirect and mediated by complex biological changes, behaviors, and social determinants. In the instance of suicide, a range of self-destructive behavior can lead to death. In the instance of premature mortality, the mechanisms are diverse, indi- rect, and related to the pathogenesis and course of several diseases of mid-life, but nonetheless real and devastating. e next sections consider suicide and premature mortality in that order before moving on to a discussion of disability as an outcome.

A recent analysis based on the ECA data found that of 11 disorders studied (including anxiety, depression, substance dependence, and antisocial personality disorder), only drug and alcohol dependence or abuse and antisocial personality disorder incurred signi cantly higher mortality risk. Five to 15 years of life were lost from these disorders.53:1366


Suicide is the taking of one’s own life (from the Latin, sui, of himself, caedere, to kill). Not all suicides are associated with mental disorders, but mental disorders account for the majority. It is estimated that 60–90% of suicides are asso- ciated with a ective disorder. Schizophrenia, depression, and bipolar illness contribute to the number of suicides. Suicide was the tenth ranked cause of death in the United States, accounting for 38,364 deaths in 2010.54,55 It was the seventh leading cause of death for men and the fourteenth for women. In men, suicides outnumber homicides by more than 2 to 1 and are epidemic in the sense of being com- mon, outnumbering deaths from HIV by nearly 4 to 1.54–56 Suicides are most common among young and middle-aged adults; however, it is important to note that rates of suicide rise sharply for men older than 70 years of age, with a rate of suicide for those aged over 75 years of 36 per 100,000.54,57 Men have higher rates than women by a ratio of 4 to 1 and account for 79% of suicides.56,57 e ratio increases to 6.9 to 1 in individuals older than 65, in particular Caucasian men, because men and women of color manifest lower rates of suicide in their advanced years.57

Suicide is the third leading cause of death among young people aged 15–24 (unintentional injuries and homicides are number 1 and 2) and second in those aged 25–34

(topping homicides).56,57 e gender ratio for suicide is high in younger cohorts: 7.6 males to 1 female in 15-year-olds compared to 4.8 to 1 in young adults aged 20–24 years. Suicidal ideation occurs in about 16% of youth.58 Suicide rates are much higher in the western United States (with the exception of California) and Alaska. In 2010, rearms were used in 50.5% of suicides, su ocation in 24.7%, and overdoses (poisoning) in 17.2%. Men account for 87% of rearm suicides.56,58 Contrary to popular opinion, suicide is not more common around the winter holidays; actually, the months with the highest rates are July and August, with rates of 1.2 per 100,000 population, accounting for nearly 20% of suicides.56:15 Attempted suicides are very unreliably reported, and it is estimated that there is one suicide death for every 25 attempted suicides.58

e descriptive epidemiology of suicide is the founda- tion for enumerating risk and protective factors. ese are incorporated into the formal assessment of suicidal risk carried out in every clinical setting, most frequently emer- gency rooms (ERs). In the absence of a simple, single cause of suicide, an assessment of suicidal risk is predicated on a complex algebra of positive and negative factors. Factors that elevate risk are mental disorders, alcohol or substance use, pessimism, hopelessness, aggression, impulsivity, a past personal history of a suicide attempt, a family history of a suicide attempt, a past history of trauma, and the recent diagnosis of a serious medical illness.58–62 Environmental factors increasing risk include availability of a lethal means, social isolation, recent loss, and the occurrence of “conta- gious” clusters. Barriers to accessing care and stigmatization also raise suicide risk.

Many protective factors are reciprocals of risk factors; these include strong family and social support, absence of a lethal means, and access to care. Other protective factors include problem-solving skills, con ict resolution skills, and religious beliefs that discourage suicide.59,61 In addi- tion, in every clinical assessment of suicidal risk, there is the ill-de ned factor of clinical judgment, which is highly weighted. Clinical judgment incorporates the integration of risk and protective factors plus clinical experience and intuition based on a therapeutic relationship with an indi- vidual and years of practice.

Stemming from pharmaco-epidemiologic data, the use of antidepressants is a controversial factor in the risk of suicide. It is well-known clinically that a deeply depressed person who begins to feel better and more activated may act on suicidal ideation. Psychiatric clinicians are trained to monitor the early stages of antidepressant treatment for this possibility. Data from the US Food and Drug Administration (FDA) identi ed an elevated risk of suicide


attempts in teens taking antidepressants, thus leading to a black-box warning on certain medications. In 2003, evalua- tion of antidepressant trial information raised concerns that antidepressants may increase the risk of suicide.63 Other studies, mostly of an observational nature, have suggested that antidepressants actually are protective. For example, Jick et al. found that individuals on antidepressants for less than 30 days had no di erence in risk of suicide than those on antidepressants for more than 30 days (Odds Ratio [OR] = 1.0, 95% Con dence Interval/CI [0.4, 2.3]).64:217 Simon found decreasing suicide risk a er antidepressant initiation in both adolescents and adults.65 Studies suggest that with the rise in treatment of depression in youth, sui- cide rates declined and, with the addition of the black-box warnings about suicide, rates of suicide increased in asso- ciation with declining rates of antidepressant treatment.66 However, these were purely ecological relationships and cannot be considered causal. In the end, the use of antide- pressants requires careful evaluation of risks and bene ts using seasoned clinical judgment.

Prevention of Suicide

Knowledge of risk and protective factors and clinical assess- ments are a foundation for prevention, especially when there is an opportunity to evaluate someone with suicidal ideation. Indeed, 67% of people who commit suicide are receiving treatment at the time. e National Violent Death Reporting System (NVDRS) nds that 31% of suicides were in individuals currently receiving mental health treatment, and 44% had a currently diagnosed mental health prob- lem.56:18 Beyond that, a plan for prevention of suicide, given no simple cause, is a complex matrix of interventions. ere is a long history of progress in trying to prevent suicide in the United States, starting with the establishment of a US Public Health Service (USPHS) Suicide Prevention Center in 1958. e culmination of developments over the years was the publication of the Surgeon General’s national strat- egy for suicide prevention in 2001 (updated in 2012).18,67 e 2001 plan included a matrix of activities (see Table 7.1) and called for preventing suicide over the life span, reduc- ing the rate of suicidal behaviors, reducing the harmful a er-e ects of suicides, and promoting resiliency. e plan had three parts: heightening awareness of the problem, dis- seminating interventions, and enhancing methodologies for surveillance and studies of suicide. e Surgeon General summarized a range of interventions using the matrix of universal, selective, and indicated actions discussed earlier. e updated strategy accounts for new research results and focuses on four strategic directions: supportive environ- ments to promote the mental health of individuals, families,

Figure 7.2

National Strategy for Suicide Prevention


and communities; enhancing preventive services; timely treatment and support; and improvement of suicide pre- vention surveillance, research, and evaluative activities (see Figure 7.2).


e challenge of improving life expectancy among people with SMI is, perhaps, the leading public health task for psychiatry today. To achieve this objective, psychiatry must develop new ways of partnering with primary care prac- titioners to ensure that the comprehensive care needs of this population are met (see Chapters 5 and 10). In 2006, the NASMHPD documented a 25-year shortened life expectancy of people with SMI.25 As a result, the National Centers for Disease Control (CDC) began to monitor mortality rates in the United States for this high-risk group.

Two major surveys provide information on the prob- lem of comorbidity: the National Survey on Drug Use and Health (NSDUH) and the National Health Interview Survey (NHIS). e NSDUH provides information about the physical health of individuals with mental ill- ness.68 In addition to identifying the prevalence of mental illness, this survey also identi es comorbid conditions in those with mental illness. Nearly 20% of adults aged 18 or older had a mental illness; 6.5% had major depressive episode, and 4.6% had an SMI. Individuals with depres- sion or any mental illness had signi cantly higher rates of

hypertension, asthma, diabetes, heart disease, and stroke than did those without these disorders. In addition, those with SMI had signi cantly higher rates of hypertension, asthma, and stroke, whereas rates of diabetes and heart disease approached signi cance compared to those with- out SMI.68:2–3 Use of hospitals or ERs was higher in those with mental illness compared to those without mental ill- ness (15.1% vs. 10.1%; and 38.8% vs. 27.1%, respectively). Similar results were present in both those with SMI and major depressive episodes compared to those without SMI, with hospital use of 20.4% vs. 11.6% and 18.1 vs. 10.8%, respectively; ER use was 47.6% vs. 30.5% and 43.3% and 28.7%, respectively.68:4–5 Unfortunately, this survey cannot identify the order of onset or whether having one disor- der increases the risk of another due to the cross-sectional nature of this information.

e causes of premature mortality are found in the ravages of chronic diseases such as hypertension, diabetes, and vascular disease. An early harbinger of the problem is the metabolic syndrome, characterized by high blood pressure, high blood glucose, and high blood cholesterol. Unfortunately, the medications that have revolutionized the care and treatment of mental illness also increase the risk of metabolic syndrome, diabetes, and cardiovascular disease in those treated. ose with SMI die an average of 15–25 years earlier than the general population.69,70 ese problems are intensi ed by low rates of disease monitoring in those with SMI.71 e solution to the problem requires mental health professionals and community mental health centers to address the medical care of people with SMI. e four-quadrant Behavioral Health Primary Care Integration Model is one framework that helps to distinguish ways to plan for services to provide care for both needs.72 For example, in those with high behavioral health needs, one method is to integrate primary care into mental health ser- vices. Alternatively, within federally quali ed health cen- ters, greater integration of mental health care into primary care addresses the problem. ese two major platforms of care and the issue of premature mortality are discussed in greater detail in Chapter 5.

e second source of data is the NHIS. Based on a community sample, it is a household survey of adults that provides additional information about the presence of SMI in addition to a wide range of health variables.73 Social and economic factors contributing to the risk for chronic health problems in the seriously mentally ill include a higher fre- quency of living below the poverty level (35.3% SMI vs. 11.4% with no SMI, p < 0.001), homelessness (35.6% SMI vs. 4.8% with no SMI, p < 0.001), lower education (55.2% SMI vs. 44.3% with no SMI, p < 0.001), lower rates of

working in the past year (50.2% SMI vs. 82% with no SMI, p < 0.001), higher rates of use of government or other assis- tance (p < 0.001), and higher frequency of having unmet care needs in the past year due to cost (p < 0.001).73:1044–1045 In addition, behavior risk factors are signi cantly higher in those with SMI. For example, 51.4% smoke vs. 19.1% of those without SMI (p < 0.001); 52.1% do not exercise vs. 38.6% of those without SMI (p < 0.001); and 32.4% are obese vs. 26% of those without SMI (p = 0.01).73:1044 Also, there were signi cant di erences in the prevalence of heart problems (19.8% SMI vs. 11.1% with no SMI, p < 0.001), lung problems (24.9% SMI vs. 9.9% with no SMI, p < 0.001), and hypertension (31.2% SMI vs. 23.6% with no SMI, p < 0.01).73:1044 Finally, there was a signi cant dif- ference in the frequency of chronic conditions: 33.7% of those with SMI had one chronic condition versus 23.3% of those without SMI, and 25.7% with SMI had two or more chronic conditions versus 15.6% without SMI.73:1044 In the past year, 47.2% had one or more ER visits, and 24.3% had one or more hospital stays versus 19.5% and 9.0% of those without SMI, respectively (p < 0.001 for both).73

Achieving the goal of reducing premature mortality will require addressing a problem identi ed at the dawn of modern public psychiatry as part of the community mental health movement but never successfully resolved. Although, the SAMHSA launched a “10 by 10” public awareness program (10-year improvement in shortened life expectancy by 2010), success in pursuit of this goal will take years, with not just clinical care, but also prevention and wellness programs required to make an essential con- tribution. Recognizing this challenge, in spring 2009, the SAMHSA issued a request for proposals for demonstration projects. e rst round of these demonstration projects is completed, and a second round is well under way. (One such project is described in more detail in Chapter 5.)


Disability is the impact of disease on the social and occu- pational performance of the individual.74 Disability is not the same as symptoms from chronic disease, although o en the two are confounded. is confusion is understandable because acute psychological and behavioral symptoms can interfere with performance. is interference is temporary during the acute symptomatic phase of illness. It is well known that, given the limitations of psychiatric treatments, residual symptoms are common, thereby contributing to interference with performance and activities of daily living. Other factors, such as institutionalization or social isolation,


contribute to disability as well. Psychosocial rehabilitation services are designed to target disability (see Chapter 4).

In combination, symptoms and disabilities form the broad clinical pictures encountered in public psychiatry. e distinction between symptoms and disabilities is useful not only for intellectual clarity. Understanding disability is useful for accomplishing disability assessments, which are based on assessments of capacity for self-care, social performance, and occupational behavior. Also, an understanding of disability is a foundation for planning approaches to recovery, as we now understand it in public psychiatry (see Chapter 3).

Furthermore, the concept of disability is also useful for appreciating and communicating the enormous impact of psychiatric disorders on individuals and society and com- paring this with other medical, mainly physically de ned diseases. e metric of the DALY placed psychiatric disor- ders squarely on the public health map.17 is metric, com- bining years of life lost (YLL) to premature death and years of life lived with a disability (YLD) in psychiatric disorders, when compared to other medical conditions, nds that unipolar depression, self-in icted injury, substance abuse, schizophrenia, bipolar disorder, and obsessive compulsive disorder (OCD) emerge as leading causes of disease burden. In industrialized societies, psychiatric disorders ranked in the top 10, accounting for 10.5% of the burden of disease worldwide based on ndings from the Global Burden of Disease study.17:1502

For example, the Global Burden of Disease Study esti- mated that the disease burden of unipolar major depression in 1990 was fourth of 15 leading causes. It is expected that by 2020 depression will move to the second leading cause of disease burden.75:1241 Four other mental disorders also were included in the top 10: alcohol use, bipolar disorder, schizo- phrenia, and OCD. In 2010, mental health and SUDs were responsible for 7.4% of all DALYs, and these disor- ders actually accounted for 22.9% of YLDs, the highest single proportion of all diseases.76:1578–1579 Depression was responsible for 40.5% and anxiety disorders for 14.6% of the DALYs, followed by drug use (10.9%) and alcohol use (9.6%), whereas schizophrenia accounted for 7.4%. Of all the psychiatric disorders, SUDs resulted in 86.1% of YLLs, with alcohol use resulting in 44.4% of YLLs and drug use in 41.7% of YLLs. Globally, drug dependence is the eighth largest contributor to disability in men, with opiate depen- dence contributing 9.2 million DALYs or nearly half of the burden.77:1570 is re ects a 74% increase from 1990 to 2010 for opiate dependence, with the addition of another 4 mil- lion DALYs.77:1569 Despite the higher prevalence of SUDs in 2010 (speci cally alcohol, opiates, and cocaine), mental dis- orders did not increase in prevalence over the same period.

Unfortunately, drug dependence takes its highest toll in the young adult years when productivity is o en highest, thus further augmenting the burden of this disorder.

ese epidemiologic measures are critical to justifying priorities and strategically allocating limited funds to man- age public health problems. Worldwide, psychiatric disor- ders accounted for only 0.4% of YLLs but an enormous 26% of YLDs. In 2002, the WHO identi ed mental illness as the leading cause of disability in the United States and Canada.78 is evidence is important to e orts in public psychiatry because important funding decisions o en are made based on problem rank or priority.

In short, psychiatric disorders have recently emerged as major public health problems and have begun to receive the attention they deserved. Major national organizations such as the NIMH began to incorporate plans for reduc- ing burden of disease into their strategic goals. On a service level, the recovery movement (see Chapter 3) and early intervention in psychosis (see herein and Chapter 10), two major innovations in psychiatric services, became impor- tant new directions. ese programs, though not directly linked, emerged shortly a er the establishment of burden of disease as a valid and essential perspective on psychiatric disorders.

One consequence of disability is unemployment, a circumstance o en experienced by persons with SMI. For example, a recent analysis found that individuals had an 18% decrease in likelihood of employment for each unit increase in emotional problems causing di culty in accom- plishing goals.79:13 e risk was greater for women (22% decrease in employment) than for men (11%). Broadhead identi ed that the greatest burden of all diseases on families and society are lost work days resulting from depression, with 4.78 times the risk of disability days (95% CI [1.64, 13.88]) and an average of 11 days of disability due to symp- toms compared to 2 days in asymptomatic individuals.80:2527 Individuals with major depressive disorder were more o en unemployed compared to those who were asymptomatic (44.7% vs. 30.2%).80:2526

In this section, the discussion reviewed evidence of the importance of morbidity, mortality, and disability as essen- tial outcomes to consider in public psychiatry. Absence of change in indicators of morbidity suggests a need for new paradigms for clinical diagnosis and research. Rates of mor- tality and disability of psychiatric disorders were largely ignored until 25 years ago, yet they place psychiatric dis- orders at the top of public health concerns in the United States and the world. Public psychiatrists need to under- stand these gures, not only because epidemiologic data inform practice, as in the case of suicide prediction, but


also because data on these outcomes, among other indica- tors, reveal the “community diagnosis” of the places where they work.


Although early intervention is reviewed thoroughly in Chapter 10, it is mentioned here because of its role in reducing burden of disease and, conceivably, its potential for actually preventing full-blown psychotic illness. It is well known that the earlier it is possible to intervene in an incip- ient psychotic illness, the lower the risk of long-term dis- ability. Strategies for the early identi cation of cases enable multidimensional treatment, including pharmacologic interventions, education, work-related cognitive coaching, and family psychoeducation. All of these then have a bet- ter chance of remediating the psychotic symptoms. Indeed, in some cases, the risk of a orid psychotic episode may be averted, and this may qualify as primary prevention. As we noted earlier, this type of intervention considerably rebal- ances the public psychiatry portfolio of services and appro- priately emphasizes the prodrome of psychosis and the earliest stages of symptoms.

e concept of early intervention harkens back to central ideas of the community mental health movement, and it is intuitively convincing in a theoretical frame- work derived from public health. However, the e cacy of early intervention in initial episodes of psychosis is still unproved, and many studies are now under way to evalu- ate it (see Chapter 10). In addition, more e ort is needed in the form of advocacy for health insurance bene ts to cover the elements of care in an early intervention pro- gram. Success in obtaining reimbursement would provide incentive for community mental health clinics to imple- ment the services.



An interesting recent initiative in public education about mental illness is Mental Health First Aid (MHFA), devel- oped in Australia in 2001 by Anthony Jorm and Betty Kitchener.81 It was introduced into the United States in 2008 via a national campaign that is a collaboration of the National Council for Community Behavior Healthcare (NCCBH) and the Maryland and Missouri state departments of mental

health. MHFA is supported by a growing body of evidence (see website review, National Registry of Evidence Based Programs and Practices [NREPP]).82 is program provides manualized training for people who are not mental health professionals, such as teachers or rst responders. e train- ing helps people to identify, understand, and respond to people with mental illness or addictions. MHFA is applica- ble to many high-risk populations such as college students, young adults, and communities su ering from traumatic occurrences. Key elements of MHFA include assisting the person facing a crisis, listening nonjudgmentally, o ering support, o ering information, encouraging the person to get professional help, and encouraging use of supports.83:237 A campaign to promote MHFA nationwide is supported by a website (mentalhealth Surveys a er imple- mentationofMHFAshowsimprovementinbeliefsabout mental health professionals and treatments.83:238


Among the public health challenges facing public psychia- try is disaster planning in anticipation of epidemics such as in uenza and natural or man-made, disasters.84,85 Behavioral interventions are an essential part of disaster planning. ese exercises are an opportunity for public psychiatry to demonstrate its role and importance in responding to the national security agenda.

Since September 11, 2001, the role of public psychia- try in preparation for response to natural and man-made disasters has been further accentuated.84,86 Planning is usu- ally coordinated by state government authorities in collabo- ration with local government and community resources. Public psychiatry, by planning and working with civil and other medical experts and resources, demonstrates its role in helping the psychiatric casualties of such events.

A common problem a er disaster is the negative e ects on an individual’s emotional well-being, typically with psychological sequelae being greater than physical.84,87,88 McCabe et al. identi es a need to prepare for a surge in the need for behavioral health care regardless of the kind of disaster experienced.84 Disaster planning must address a variety of problems and groups, starting with the need of the entire population for information during events. Regular communication about the disaster event, updates about loss and resolution of services, and information about resources available in the community that support coping are essen- tial to support healthy coping and promote health. Planning for how those with existing physical or mental health


problems will receive needed services without interruption, including physical and mental health care, medications, and other resources required for normal functioning, is essential. In addition, plans must identify how psychological support and screening can be implemented in the midst of each phase of a disaster and its a ermath. Plans o en include use of pro- fessionals, paraprofessionals, and lay volunteers in provid- ing an array of needed services. O en, volunteers trained in MHFA can provide support, screening, and referral to pro- fessional services. It is well known that with disaster comes increased need for clinical services: proper planning can ensure that vital services are available when disasters strike.

One of the great challenges for US society is the preven- tion of future tragedies such as the Sandy Hook Elementary School shootings.89,90 In the absence of single, high-impact solutions, some combination of public education, early intervention, improved access to clinical services, and adequate service capacity are the best, most comprehen- sive strategy for heading o another such incident. Health policy also plays a role in addressing risks and needs in the community, whether related to restricted access to lethal weapons as a universal precaution, the role of involuntary treatment, and the availability of professionals to provide clinical services.


e future of public health in psychiatry lies in the integra- tion of knowledge related to environmental and sociocul- tural factors that impact risk for mental illness. e Surgeon General’s 2001 report on culture, race and ethnicity was a landmark in conceptualizing and reviewing evidence for secondary and tertiary preventive interventions to reduce burden of disease from psychiatric disorders.19 It identi- ed culture, race, and ethnicity as risk factors, with each de ning high-risk groups for burden of disease. e docu- mented disparities in mental health outcomes serve as a starting point. Disparities theoretically occur as a function of elevated incidence, higher risk of mortality, or chronic illness and disability—the three outcomes discussed earlier. From descriptive epidemiology, there is no evidence of dif- ferences in the incidence in psychiatric disorders among broad, national cultural groups. Rather, it is the higher risk of chronic morbidity, mortality, and burden of disease that accounts for the disparities.

Key mechanisms for the disparities are complex, operate at multiple levels, and require a transformation of the health care system.91 For example, a recent Health and Human Services Action Plan to address racial and ethnic disparities targets systems-level factors including infrastructure and workforce development, large-scale health promotion and wellness initiatives, support for scienti c innovation, and administrative accountability.91 ese systems-level e orts complement pervasive challenges of diminished access to and quality of care for racial and ethnic minori- ties that result in prolonged symptoms and disability.19 Recent e orts have begun to conceptualize culture more broadly to include other social identities, such as gender, sexual orientation, social class, religion, and so on, that can result in discrimination or marginalization due to one’s identity.92,93 Adopting this broader de nition of cul- ture is likely to enhance the conceptualization of health disparities research to include the intersection of various identities (e.g., race, gender, class) to inform research and intervention.94


Public health policy supports a population perspective in clinical practice in the form of practice-based population health.95,96 Berwick’s discussion of the triple aim to improve health care in the United States identi es a need for (1) a focus on high quality, (2) population-focused health care, and (3) accountability to control cost.97 He later cham- pioned this agenda during his term as Administrator of Medicare and Medicaid Services. Promoted under the A ordable Care Act (ACA) by the Centers for Medicaid and Medicare Services (CMS) for the purpose of cost control in high-risk, high-cost patients in accountable care organizations, this model creates a new standard for clinical practice. Clinicians are responsible not only for patients who present for treatment, but also for an entire panel of potential patients, including those who do not attend the clinic.

Responsibility for the whole panel encourages service delivery systems to develop preventive and wellness inter- ventions. is type of practice is supported by risk-based, prepaid reimbursement mechanisms in place of volume- driven, fee-for-service mechanisms. Primary care practices will have to re-engineer for this type of practice, which will be integrated through accountable care organizations (ACOs), within medical homes for people with SMI, and


in community health centers and integrated care teams for patients with psychiatric illness98 (see Chapter 5).


A basic premise for this chapter is that public health con- cepts and practices should be integrated into the clinical model of public psychiatry. A critical juncture between the two is at the forefront of the development of practice-based population health, a new service delivery model for public psychiatry and the rest of medicine (see Chapter 5).

As noted earlier, TCC is an exemplar of an academic prevention program that is part of the CMHC. We high- light it as a case example to illustrate how prevention oper- ates and how it can support population practice.


In the late 1970s at the CMHC, at a time when federal, categorical community mental health funding was falling, prevention programs were consolidated into a single-unit named e Consultation Center. ese programs fol- lowed a community consultation and prevention research agenda focusing on a broad range of prevention and health promotion topics. Over the years, TCC has pursued mul- tiple grant and contract-supported projects.7 In 2005, the National Institute on Drug Abuse (NIDA) awarded the Center and its companion research division in the Yale Department of Psychiatry (the Division of Prevention and Community Research) a training grant to support prevention research education for postdoctoral fellows. As a result of these e orts, TCC became a nationally rec- ognized leader in prevention education that is virtually unique.

In this way, through a long fallow period for inte- grated public health and public psychiatry, TCC helped to maintain expertise in public health and prevention at the CMHC. is story is an example of an academic program sustaining an important stream of public psychiatry that was at risk of withering away because of funding, ideologi- cal, and service vicissitudes. When national policy discus- sions through the NFC report in 2003 returned to the topics of prevention and early intervention, TCC was an important building block for participation in the transfor- mation agenda.

TCC’s mission is to promote health and wellness, pre- vent mental health and substance abuse problems, and enhance equity and social justice (www.consultationcenter. is work is done in collaboration with com- munity organizations, schools, businesses, and govern- ment agencies as well as with mental health consumers, family members, service providers, and other community stakeholders.

Center services and research target vulnerable popula- tions, such as individuals living in poverty or those expe- riencing trauma or exposure to stressful family, school, or neighborhood environments. Prevention services and research include both risk reduction and health promotion strategies as appropriate, are theoretically grounded, and take into account key developmental and cultural contexts. A hallmark of the Center’s research is close collaboration with key community stakeholders to e ect change. ree ongoing projects are illustrative (1) the Yale-Bridgeport Gear-Up, a universal preventive intervention to reduce high school dropout and increase college entry for under- represented minority youth99; (2) the Youth Development Training and Resource Center or YDTRC (http://ydtrc. org), formed more than 20 years ago as a collaboration among a network of youth-serving agencies in Greater New Haven (Connecticut) with the goal of a ecting individual and systems change to promote youth develop- ment100; and (3) the Family Violence Program, a selected prevention intervention that provides a 9-week psycho- educational alternative to prosecution for adults arrested for domestic violence; the program, now in its twentieth year, seeks to prevent recurrence by teaching participants how to cope more e ectively with anger, stress, and frus- tration in intimate relationships.101 e prevention work is conceptualized less as disease prevention in individuals or as prevention of psychiatric disorders, and more broadly as community- and population-level strategies to promote behavioral health. ese approaches are likely to have an impact on the socioecological conditions that cause, exac- erbate, or sustain disorders and are an important focus of prevention.

Current challenges include ongoing engagement with clinical services at the CMHC to build a robust approach to practice-based population health. In contrast to the services just described, these new initiatives are disease- oriented. A range of consultations are under way, including (1) routine depression screening for the panel of patients served by the CMHC (a universal health educational and preventive intervention); (2) the indicated intervention of routine, structured screening for suicidal ideation among people with major depression during evaluation; and (3) collaborations with an early intervention program to reduce risk of metabolic syndrome (a selective prevention). Over time, the goal is to re-establish the close collaboration


between prevention and clinical interventions that origi- nally characterized the community mental health center movement and is now necessary for practice-based popula- tion health.


Psychiatry cannot be divided into “organ systems” as much of our medical system organizes care. Integrating the focus of who should be targeted for intervention with current sta- tus on a health–disease continuum o ers an approach that acknowledges the complexity of the mental health–mental illness continuum. is continuum is broad enough to pro- vide a foundation for population-based e orts at enhancing wellness; promoting health; and simultaneously preventing disease, complications, and comorbidity and limiting dis- ability and chronicity. Although clinicians in public psychi- atry may focus primarily on intervention, a scienti c public health perspective can target points where prevention or intervention are most warranted. Truly methodical, com- prehensive planning that weaves between levels and types of intervention is required to address the complexity inher- ent in mental illness. e point of public health in public psychiatry is to think broadly and in a multilevel frame- work and to address the structural inequalities present in our society that result in risk for mental health problems.


e mental health system has changed drastically since the era of the asylum, and it currently serves individuals within their own communities. Public health approaches and tools have enhanced psychiatry’s ability to identify and respond to changing needs for clinical care. e integration of clinical and public health approaches in public psychia- try provides strategies to assist in meeting future challenges in caring across the continuum of health for individuals, groups, and community populations.

A public health approach in psychiatry o ers a unique lens with which to identify needs and plan to improve the health of individuals, groups, communities, and large pop- ulations. Depending on the focal length of the lens, epide- miologic methods o er ways to prioritize needs and plan, implement, and evaluate interventions. Using a broad lens, universal strategies promote mental and physical health and prevent the occurrence of physical and mental ill- ness. With greater focus, groups at risk for mental illness

are identi ed and strategic interventions implemented. In focusing on speci c groups or individuals experiencing mental health problems, interventions home in on allevi- ating the symptoms and consequences of those disorders, thus preventing complications, comorbidities, and, when possible, the disability and persistence or chronicity of illness.


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Reena Kapoor, Susan Parke, Charles C. Dike, Paul Amble, Nancy Anderson, and Howard Zonana


• Forensic psychiatry and public psychiatry have become intertwined in the past 50 years because of important historical and legal factors, such as deinstitutionalization, mass incarceration, and changes in civil commitment criteria.

• Due to the overcrowding of prisons and their inability to provide adequate psychiatric treatment, specialized mental health courts and jail diversion programs have been developed to reduce the number of persons with mental illness in correctional settings.

• Community programs for forensic populations should provide individualized, recovery-oriented treatment that balances patient wishes with community safety.

• Public psychiatric hospital beds are largely devoted to the management of forensic patients who o en require specialized treatment and oversight by courts or quasi-judicial boards.

• Because of the large proportion of forensic patients in public-sector treatment settings, all public psychiatrists should acquire some knowledge of forensic psychiatry, particularly in the areas of risk assessment and legal regulation of psychiatric practice.

• orough risk management requires an understanding of actuarial (i.e., static) and dynamic risk factors for violence.

• Forensic psychiatrists can play an important role in consulting with treatment teams about risk management. e consultation is most bene cial when teams formulate a speci c question for the consultant and gather key information about the case beforehand.


Forensic psychiatry and public-sector psychiatry were not always the intertwined specialties they are today. However, as the deinstitutionalization movement of the 1960s resulted in large-scale release of patients from state psychi- atric hospitals into the community, forensic psychiatrists, with their specialized knowledge of risk assessment and legal regulation of psychiatric practice, became an essential part

of public-sector mental health care. In inpatient settings, forensic psychiatrists served both as treatment providers and as risk consultants as the few remaining state psychi- atric beds were largely devoted to treating forensic patients. In outpatient settings, community mental health centers were tasked with managing dangerous patients a er release from long-stay forensic hospitals or prisons, and forensic expertise helped to guide treatment decisions. Furthermore, as prison populations swelled to massive proportions in


the 1990s and 2000s, public sector and forensic psychia- trists joined forces with criminal justice agencies to create alternatives to incarceration for individuals with mental illness. e end result was that public psychiatry and foren- sic psychiatry became engaged in a long-term, multifac- eted endeavor: managing persons with mental illness who exhibit dangerous behaviors or are involved with the crimi- nal justice system.

is chapter traces the historical developments that have led to our current practice of integrating forensic and public-sector psychiatry, and it delineates the areas in which public-sector psychiatrists must acquire knowledge about forensic issues in order to practice e ectively. First, we discuss the management of inpatient forensic units in state hospitals. Next, we discuss the growth of outpatient treatment programs for forensic patients, both as alterna- tives to incarceration and as a er-care programs for indi- viduals released from inpatient forensic units. We provide a conceptual framework for public-sector professionals inter- acting with the criminal justice system (court, probation, parole). Finally, we discuss violence risk assessment and management, focusing on the essential skills that public- sector psychiatrists should acquire, including when to ask for forensic and/or legal consultation.


In colonial times, jails, prisons, and homes were used to con ne persons with mental illness. As early as 1694—long before asylums or large correctional institutions had been constructed—the Massachusetts Bay Colony passed a stat- ute for the con nement of persons with mental illness, cit- ing dangerousness as the major criterion for con nement.1 A New York statute from 1790, with one section that addresses the “furiously mad,” is another example of an early commitment statute2:

And whereas there are sometimes persons, who by lunacy or otherwise, are furiously mad, or are so far disordered in their senses that they may be danger- ous to be permitted to go abroad; erefore, be it further enacted . . . at it shall and may be lawful for any two or more justices of the peace, where such lunatic or mad person shall be found, by warrant under their hands and seals, directed to the consta- bles and overseers of the poor of the city or town, or some of them, to cause such person to be appre- hended and kept safely locked up in some secure place within such city.

e terms “furiously mad” or “dangerous” were not de ned, and justices of the peace were given broad powers to con ne persons as they saw t, including chaining them if necessary. e law also a rmed the appointment by the chancellor of guardians or family members to care for the ill person. In this era, con nement had little to do with treat- ment. No mention of physicians, as experts or custodians, was required. ere were no explicit statutory time limits on the con nement, although some courts required judicial review a er the initial con nement.3

e years between 1820 and 1970 saw the develop- ment of more humane prisons and mental health facilities in the United States. Psychiatric treatment centers that focused on moral treatment, such as the Friends Hospital in Philadelphia and the Hartford Retreat in Connecticut, began o ering an alternative to the more austere con ne- ment of the previous century. In 1841, Dorothea Dix began her crusade to move persons with mental illness out of jails and prisons into separate facilities where treatment could be provided. In 1881, Massachusetts gave legal recognition to the idea of voluntary admission to a mental health facility.4 By 1924, 28 states had such laws.

Commitment laws in the rst half of the 20th century were quite paternalistic, giving broad discretion to physi- cians. Connecticut enacted a typical law, which stated that involuntary con nement required the person to be men- tally ill and a “ t subject for con nement.”5 By employ- ing such exible criteria, the legislature le most of the decision-making to physicians. However, by 1976, the “ t subject for con nement” criterion was replaced with a requirement to prove that the individual was either dan- gerous or gravely disabled. Greater procedural due process rights were also a orded to individuals facing involuntary commitment.

Stricter criteria for hospitalization, combined with President Kennedy’s Community Mental Health Act of 1963, dramatically reduced the population of psychiatric hospitals. By the early 1970s, the state hospital popula- tion dropped to less than half of what it was in the 1950s. During the same time period, the prison population began to rise, leading some scholars to postulate that individuals with mental illness were being “transinstitutionalized” from mental health facilities into correctional settings.6 is trend became clearer in the decades that followed, as prison populations continued to rise and psychiatric hospital beds fell to unprecedented levels.

Figure 8.1 depicts the phenomenon of transinstitu- tionalization, tracking prison and state hospital popula- tions during the 1930s to 2000s.7 In this study, Harcourt concluded that overall rates of institutionalization were the


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Forced to contend with a dwindling number of psychiatric inpatient beds and massive prison overcrowding, states began to look for alternative ways to manage persons with mental illness who were involved with the criminal justice system. Beginning in the 1990s, jail diversion programs gained popu- larity, with the goal of identifying individuals with mental illness and o ering them treatment rather than punishment. Two models were initially developed: those involving spe- cialty “mental health courts” and those in which diversion e orts occurred in “regular” criminal courts.11 e two mod- els used slightly di erent procedures to accomplish the same objective. In nonspecialty court programs, mental health cli- nicians were situated in the criminal courthouse and worked with patients and court personnel (prosecutors, defense attorneys, and judges) to arrange treatment programs as alternatives to incarceration. In mental health courts, a com- pletely separate court system—one with a more therapeutic focus—was created for individuals with mental illness, in the hope of developing a system with specialized expertise.

A typical individual involved in these programs is exem- pli ed by Mr. A:

Mr. A had a long history of panhandling and loiter- ing outside the local donut shop. ough he had been diagnosed with schizophrenia as a teenager, he did not believe he had a mental illness and did not take medication. He frequently used crack cocaine and drank to excess. He was homeless, alternating between local shelters and sleeping on a park bench in the town square. He was well known to law enforcement o – cers, who frequently responded to complaints from the donut shop owners, who reported that he harassed customers and negatively a ected their business. Police o ers had taken Mr. A to the emergency room for psy- chiatric evaluation several times, but he was released because he was not thought to be dangerous or gravely disabled. e fourth time that o cers were called to the donut shop to respond to complaints about Mr. A, they arrested him and charged him with breach of peace, public intoxication, and criminal trespassing. When he arrived at the courthouse for arraignment, he was considered a candidate for jail diversion. If he agreed, he was allowed to participate in a community treatment program rather than go to jail.

Prison and Jail Rate  Mental Hospital Rate Aggregated Institutionalization

Rates of institutionalization, including jails, in the United States (per 100,000 adults), 1934-2001

same in 2001 as in the 1950s, but many more persons were in prison or jail than in hospitals.

Since 2001, the prison population has continued to grow, with the number of inmates rising from 200,000 in 1973 to more than 2 million in 2008 (approximately 1% of the US adult population). A large portion of the prison population now has symptoms of serious mental illness. Although exact numbers are di cult to calculate, in 2012, there were estimated to be more than 356,000 inmates with severe mental illness (SMI) in prisons and jails. By contrast, there were 35,000 patients with SMI in state psychiatric systems. us, the number of mentally ill in jails and prisons was 10 times the number remaining in state hospitals.8

Mass incarceration in the United States has become a hot topic of political and economic concern, in part because of the disproportionate numbers of persons with mental illness who are incarcerated. By some estimates, the Los Angeles County Jail, Rikers Island Jail in New York City, and the Cook County Jail in Chicago are now the largest mental health treatment facilities in the United States.9 Correctional facilities are not the ideal placement for per- sons with mental illness. Even the US Supreme Court agreed with this position in 2011, ruling that the California prison system must reduce its population signi cantly in order to provide necessary mental health and medical treatment for its inmate population.10 Many other states have also become involved in large-scale e orts to divert people out of correc- tional facilities and into settings more suitable for mental health treatment. ese programs are discussed in the fol- lowing section.

Figure 8.1


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Intercept 1

Law enforcement/ Emergency services

Dispatch 911



Intercept 2

Initial detention/Initial court hearings



Intercept 3




Intercept 4


Intercept 5

Community corrections/ Community support




Jail Re-entry



Figure 8.2 Sequential Intercept Model16

Early data from jail diversion programs and mental health courts were promising. Programs consistently dem- onstrated a reduction in jail days for persons with mental illness, and most programs showed a high retention rate in mental health treatment a er 1 year. Equally compelling were the data that showed no adverse e ect on public safety as a result of diversion, even for individuals with signi cant histories of violence.12,13 Cost savings were also substantial. Although di cult to calculate because of the many indi- rect savings from jail diversion, programs were able to suc- cessfully demonstrate savings from reduced arrest/booking costs, jail days, court costs, and emergency room visits.14 As a result, jail diversion programs and specialty courts expanded rapidly. By 2007, more than 500 jail diversion programs had been developed around the country.11

E orts to divert persons with mental illness from the criminal justice system at other junctures—for example, pre- booking or post-incarceration—also ourished. Police o – cers received crisis intervention training to identify signs of mental illness and divert individuals to treatment instead of arresting them.15 In addition, community reentry programs were developed for individuals with mental illness who were released a er long incarcerations, with the aim of providing support and increasing their chances for successful commu- nity reintegration. Together with traditional jail diversion programs, these additional e orts make up the Sequential Intercept Model of criminal justice diversion16 depicted in Figure 8.2.

Today, community mental health centers are com- mon treatment settings for individuals diverted from the

criminal justice system. In addition to traditional psychiat- ric treatment—therapy and medication—the mental health centers o er robust ancillary services, such as case manage- ment, housing, and vocational support. e nature and intensity of these services varies greatly due to patients’ needs and available resources. However, most models of caring for forensic patients are based on an interdisciplinary team approach involving collaboration among physicians, other mental health clinicians, case managers, and court o cers.



Several collaborative models of outpatient care for individ- uals with serious mental illness and criminal justice involve- ment have been developed. One of the most prevalent of these models is Forensic Assertive Community Treatment (FACT). FACT teams provide the same level of care as tra- ditional Assertive Community Treatment (ACT) teams, but di er in a few ways. FACT programs typically have (1) enrollees with criminal justice involvement, (2) refer- rals primarily from a criminal justice agency, and (3) a close partnership with a criminal justice agency.17 Although ini- tially promising, longer-term outcomes of FACT teams have yet to be evaluated. A few studies have attempted to evaluate FACT outcomes, but methodological limitations make it di cult to draw conclusions from the data.18 FACT



Law Enforcement Contact

Initial Detention Initial Hearings

Probation Parole



programs are widely employed, but their evidence base lags far behind the pace of implementation.

Mandated outpatient treatment, sometimes referred to as “outpatient civil commitment,” has also been used to manage psychiatric patients with the aim of reducing arrests, incar- cerations, and psychiatric hospitalizations. As with FACT programs, data regarding outpatient commitment are mixed. e American Psychiatric Association cautiously endorsed the idea in a 1999 resource document,19 but studies since then have indicated that the programs are not as e ective in producing outpatient compliance as anticipated.20 Some scholars now believe that the main bene t from outpatient commitment comes not from the threat of legal sanctions, but rather from the coordinated and intensive treatment e orts being provided to the committed individuals.


Community treatment providers help forensic patients with serious mental illnesses and substantial violence risk to live safely in the community. e primary goal is to improve the health of the patient, but clinicians must also be mind- ful of additional treatment goals related to the criminal jus- tice system:

• Reducing recidivism and rearrest

• Compliance with criminal justice mandates (i.e., probation or parole stipulations)

• Maintaining community safety
All community forensic treatment programs have sev- eral features in common. eir focus on a multidisciplinary approach involving psychotherapy, medication, case man- agement, housing and vocational supports, and (o en) legal oversight is essential for providing adequate care to this high-risk population. Many forensic programs also include:

• “In-reach” into prisons and secure hospitals, so that clinicians and patients can begin working together months (or even years) prior to community placement

• Access to varying levels of psychiatric care, from residential dual-diagnosis units to day hospitals to emergency and inpatient services

• Housing programs, because nding adequate housing can be challenging with this population, particularly for sex o enders and others with residency restrictions

• Vocational programs, because jobs are very di cult to nd for those who are doubly stigmatized by a criminal record and mental illness

• Focus on risk assessment and management, with available consultation from forensic psychiatrists and/or hospital legal representatives

• Focus on sta wellness, because clinician burnout can be heightened when working with forensic patients

• Interventions to address criminogenic needs, in addition to mental health needs, because untreated mental illness is not the only cause of criminal recidivism

• Regular communication between the multiple agencies involved in di erent aspects of care in order to coordinate treatment e orts

When implemented correctly, community forensics programs can provide excellent, recovery-oriented men- tal health care to a majority of patients. However, forensic patientsposemanyuniqueclinicalandadministrativechal- lenges, and the course of treatment is not always smooth.


At the outset, deciding which patients should be treated in an outpatient forensics program can be challenging because most patients in public-sector settings have at least one risk factor for violence. When screening patients for forensic diversion or re-entry programs, a diagnosis of SMI is required. However, some diagnoses—borderline personality disorder, developmental disabilities, impulse control disorders—fall into a “gray zone” of seriousness, and programs are le to make clinical judgments about whether the patient ts into the proposed treatment scheme. Depending on the availabil- ity of treatment services, the patient’s level of interest, and the severity of presenting symptoms, such patients may be accepted into community forensic treatment.

Community forensic programs were originally expected to treat patients with SMI who had been arrested for rela- tively minor crimes. Initially, the programs did not accept patients with histories of violent crimes, sex o enses, or serious weapons charges. However, as the programs have gained experience, they have slowly expanded to serve patients with sex o enses, histories of serious assault and homicide convictions, and patients found not guilty by reason of insanity (NGRI). ese patients return to the community a er years of incarceration or psychiatric hospi- talization, and they require a high level of monitoring and


risk management, as well as additional clinical skills to pro- vide adequate treatment.

When engaging forensic patients, risk-based and avoidance-oriented criminal justice approaches are not enough. Approaches such as the Good Lives Model (GLM) of O ender Rehabilitation,21 a strengths-based rehabilita- tion model, have focused instead on building capacities and strengths in order to reduce the risk of reo ending. GLM is responsive to individuals’ particular interests, abilities, and aspirations, working toward their personal goals without harming others.

Substance use is a major risk factor and treatment chal- lenge for this population. Criminal justice agencies require abstinence to comply with legal stipulations, but many patients continue to use substances. Incarceration is usu- ally not an option, nor does it provide the necessary treat- ment for substance use disorders. Forensic patients are o en referred to intensive substance abuse programs for treatment, but many of them are excluded because of severe mental illness symptoms or a prolonged period of absti- nence during incarceration.

Last, as community forensic programs mature, many of the patients progress in their lives and begin to take an inter- est in school, work, and romantic relationships. Clinicians embrace recovery-oriented care when approaching these issues, but sometimes the patient’s multiple treatment goals con ict with one another. For example, a patient with a history of sexual violence involving teenagers may wish to attend high school or college classes a er incarceration, and the patient’s interests in getting an education must be weighed against the potential risk posed to the community. Interdisciplinary team meetings, both with and without the patient present, are o en helpful in sorting through these di cult decisions.


Public-sector psychiatrists are involved in all aspects of recovery-oriented outpatient treatment. ey join discus- sions about potential new referrals, reviewing prior risk assessments and consulting regarding plans for community services. When new patients are admitted, psychiatrists collaborate in comprehensive clinical assessments, inter- viewing patients, evaluating risk, formulating diagnostic impressions, and developing treatment plans in conjunc- tion with patients and community providers. Psychiatrists review records of previous treatment in the community, hospitals, or correctional settings. ey routinely contact providers and family members, seeking clari cation of

behaviors, symptoms, and e cacy of medication regimens. Forensic patients have o en been treated in multiple set- tings in a disjointed manner, with multiple medications and diagnoses, so this type of information gathering is essential to creating a comprehensive treatment plan.

As with all complex patients, prescribing psychotropic medication for the forensic population requires close col- laboration with clinicians, residential program sta , visit- ing nurse agencies, pharmacies, and insurance providers. Forensic patients are o en mandated to comply with mental health treatment, including medication, but in most cases they cannot be forcibly medicated as outpatients. Because of this unenforceable mandate, psychiatrists must develop skills to address patients’ concerns about their medications while holding a rm line about complying with recom- mended treatment. Discussing the consequences of medi- cation noncompliance, including the possibility of rearrest or probation violation, is a frequent part of clinical interac- tions between psychiatrists and forensic patients.

Additionally, psychiatrists collaborate with medical providers to manage comorbid medical illnesses, which are frequently undiagnosed or untreated in forensic popula- tions. An estimated 39–43% of persons returning to the community a er incarceration have at least one chronic medical condition.22 Common conditions in forensic populations include diabetes, hypertension, obesity, hepa- titis, HIV, cancer, and dementia. Untreated medical illness is both a risk factor for premature death and for criminal recidivism23 in forensic populations, so managing medical conditions is an essential part of a community treatment plan. Few patients have family or other natural supports, and they are o en dependent on program sta to help them with these problems.

Psychiatrists participate in ongoing risk assessment and crisis intervention, both in the clinic and community set- tings. is is done in conjunction with clinicians, residential case managers, diversion program sta , and police (when indicated). Regular interagency meetings with community partners establish a collaborative working relationship and a ord an opportunity to plan for crises. In addition, psy- chiatrists can educate and consult with the community case managers and other sta about working with high-risk indi- viduals whose behaviors can evoke strong feelings in the sta that must be managed in order to provide adequate care.

Most importantly, community psychiatrists are clini- cians, engaging and accepting people with SMIs who have committed serious crimes. ey join professionals of other disciplines in treating these individuals, supporting their aspirations while helping them comply with criminal jus- tice stipulations. Limiting the role of the psychiatrist to


that of “prescriber,” as has become increasingly common in outpatient clinics across the country, simply does not work when treating this high-risk, forensic population. e psy- chiatrist must take a more expansive role in the multidis- ciplinary team, including psychotherapy, risk management, and consultation and supervision of other mental health professionals.


One of the most challenging aspects of community foren- sic treatment is managing the relationship between treat- ment providers and those involved in criminal justice oversight—police, probation, and parole o cers. ere are many reasons why so many individuals with mental illness nd themselves on probation or parole. For some—typically those who have repeatedly committed “nuisance” crimes related to symptoms of mental illness—probation is used as a method of monitoring and encouraging compliance with mental health treatment. For others, probation and parole provide necessary oversight during the high-risk period fol- lowing long incarcerations for serious violent crimes. In some states, particular crimes or legal designations, such as being a registered sex o ender or a Sexually Violent Predator, are accompanied by long periods of probation and other restric- tions (e.g., electronic GPS monitoring, residency and work restrictions). us, forensic patients are very likely to inter- act with probation or parole o cers at some time, and com- munity mental health clinicians must develop strategies to work collaboratively with these agencies.

A key aspect of the relationship between clinicians and probation o cers is the management of patient con- dentiality. Mental health treatment is typically con den- tial, but forensic patients are o en mandated to waive the psychotherapist–patient privilege so that clinicians may communicate with the probation o cer. e nature and extent of such disclosures may vary from state to state, but communicating with the patient about the limits of con – dentiality is always advisable. In some states, the patient also has to waive the privilege against self-incrimination,24 and, in those cases, it is absolutely critical for clinicians to inform patients that their statements in treatment may be disclosed to criminal justice agencies. For example, many programs for the treatment of sex o enders require that patients “take accountability” for all prior crimes. If the crimes involve prior child abuse, mandated reporting statutes may force clinicians to disclose the information to the state’s child protection agency. In addition, many states also require patients to submit to polygraph tests as part of sex o ender

treatment programs, with the consequences of revealing information about current or past crimes governed by stat- ute or case law. All of these exceptions to con dentiality can be confusing and frustrating to both clinicians and patients. However, in cases where mandatory disclosure statutes have been challenged as unconstitutional, courts have largely decided not to support rights to protect sex o enders’ con- dentiality rights because they are not viewed as a sympa- thetic group.25

In general, probation and parole o cers are not con- sidered part of the clinical treatment team, and discretion should be used in deciding how much information to dis- close to them. Some probation o cers are interested in bare- bones reports, requesting information only about whether the patient is in “good standing” at the treatment program. Others, however, request detailed information about medi- cation doses, urine toxicology results, diagnoses, and treat- ment plans. Clinicians can weigh the risks and bene ts of disclosing information on a case-by-case basis, but, given how frequently they occur, it is also prudent for mental health centers to develop institutional policies around these issues. Consultation with the Attorney General’s o ce may be helpful for state-run institutions, and hospital attorneys can consult with private mental health centers. Forensically trained clinicians may also be helpful in developing institu- tional policies that aim to protect patient–clinician con – dentiality as much as possible.


Despite the large-scale movement of most persons with mental illness out of inpatient settings in the past 50 years, state psychiatric hospitals are still necessary to treat certain groups, such as insanity acquittees and those found incom- petent to stand trial. Forensic hospital facilities usually comprise maximum-security units, medium- or enhanced- security units, and more secure “regular” inpatient psychi- atric units. What they all have in common is an increased attention to safety and security, with the maximum- security facilities being the most restrictive and secure. In a maximum-security hospital, agency security/police o cers closely monitor what patients, families, and sta bring into the facility. Security o cers prohibit materials considered potentially dangerous, and they also monitor all visits— professional, social, or family.

Patients admitted into forensic psychiatric hospitals generally fall into four broad categories: those admitted for competency to stand trial-related issues (evaluation and restoration of competency), those found NGRI,


transfers from the Department of Correction (DOC) for evaluation or treatment, and civil patients too dangerous to be managed in less restrictive settings. Most patients who are admitted for competency to stand trial-related issues come to the hospital for restoration to competency a er the court has found them incompetent to stand trial. However, in some states, patients are also sent to foren- sic psychiatric hospitals for an evaluation of their compe- tency to stand trial and restorability prior to any judicial determination. Competency restoration patients mostly come directly from correctional settings, but a small num- ber comes from the community (those who were released on bond). Patients typically arrive at the hospital directly from court, usually a er regular business hours and with- out any clinical information about their diagnosis or treat- ment in DOC. is poses a signi cant clinical challenge for the hospital sta because patients sometimes present with medical or psychiatric problems that require urgent attention, and the sta has insu cient information to manage the crisis.

Convicted prisoners who are transferred from DOC for evaluation or treatment of conditions that cannot be man- aged in the correctional setting also pose unique challenges to the hospital sta . ese patients o en exhibit a mixture of antisocial traits and symptoms consistent with traditional ideas of mental illness, such as psychosis or self-injury. ey are at high risk of engaging in violent behavior, intimida- tion, and exploitation of other patients on the unit,26 and they pose a high elopement risk. As a result, many state hos- pital systems are reticent to accept patient transfers from prisons into their “regular” forensic units. Some states have constructed specialized units just for prisoners because they are better able to meet these patients’ needs without com- promising the care of others.

A third category of forensic inpatients includes those who have been civilly committed but are too dangerous to manage in nonsecure units. Although placement of civil patients in maximum-security settings is fraught with intense scrutiny from legal and civil liberties advocates, the level of dangerousness they present sometimes makes it necessary. In such situations, strenuous e ort is made to transfer patients to a less restrictive setting as soon as the level of dangerousness abates. Managing civil patients in a maximum-security forensic unit is doubly stigmatizing and makes discharge from the facility much more di – cult because community providers look unfavorably upon patients with a history of maximum-security admission. Even if they present with minor symptoms in the future, they have been “marked” as too dangerous for nonforensic providers to handle.

A special group of civil patients in forensic units are DOC transfers at the end of sentence—inmates consid- ered too ill and dangerous to be released into the commu- nity a er serving a criminal sentence. In states with sexual violent predator statutes, these patients are o en convicted sex o enders who have been designated Sexually Violent Predators just prior to completion of the criminal sentence. When admitted to forensic hospital units, they typically do not t the mold of the typical psychiatric patient. For example, Sexually Violent Predator patients are more likely to be diagnosed with paraphilias and antisocial personal- ity disorder than with psychotic or mood disorders,27 and treatments available at the hospital may not apply to them. In addition, discharge planning is o en very complicated, given the patients’ serious violence histories and the reluc- tance of community agencies to accept them.

Forensic hospitals struggle with discharge planning for all patients, not just sex o enders. Patients can be discharged from any forensic inpatient setting, but those in maximum- security settings are usually stepped down to a less secure environment to ensure that they sustain their improvement before discharge to the community. For NGRI patients (discussed in more detail in the next section), transition back into the community is a gradual, careful, and pro- longed process with incremental increases in privileges. As the patients continue to demonstrate safety and stability in the community, they have overnight leaves from the hospi- tal, sometimes up to 7 days a week, before being condition- ally released into the community.

Forensic psychiatric hospitals play a vital role in the continuum of public sector forensic services because they carry out the dual functions of treating acutely ill and o en dangerous patients while also maintaining public safety. Forensic hospitals must contend with the demands of the patient, the patient’s attorney, civil liberties advocates, other interested parties, and heightened public scrutiny. Navigating these dual roles (patient interest vs. public safety concerns) is a daily challenge confronting forensic men- tal health practitioners, and the hospitals must necessar- ily strike a balance between treatment and safety/security concerns.


A large proportion of the remaining inpatient psychiatric beds in state hospitals are devoted to managing forensic populations, including individuals found NGRI of vio- lent crimes. Pressure to discharge these patients into the


community is no less than with civil patients, but this pres- sure must be balanced against public safety concerns. In an e ort to address this tension, some states have created psy- chiatric security review boards (PSRBs) or similar admin- istrative bodies to oversee the management of insanity acquittees. ese boards play an integral role in all aspects of the patient’s care, from initial hospital commitment to community release (typically to public-sector mental health agencies). erefore, an understanding of their develop- ment and functioning can be helpful to psychiatrists in all public-sector settings.

e insanity defense remains an area of controversy and tension between the law and mental health. Historically, individuals involved in crimes and found NGRI were com- mitted to institutions for the “criminally insane” with little oversight or special attention, but this began to change in the early 1970s as commitment procedures and treatment provided to acquittees came under scrutiny.28 In 1977, the Oregon PSRB was formed. Oregon Circuit Court Judge John C. Beatty commented on the driving forces behind the board’s creation29:

Under the then existing law, an o ender found not guilty for a crime by reason of mental disease or defect (NGI) could be committed to the Oregon State Hospital if the trial judge found him a dan- ger to himself or others by reason of the disease or defect. At the hospital the o ender was medicated until the doctors felt he was harmless and then was discharged as no longer a threat.

Jurisdiction of the court terminated with the release of the o ender by the hospital. Such persons, once discharged, rarely continued their medication and soon became as disturbed as they were before hospitalization. Not infrequently, they again com- mitted serious crimes against other persons.

Following the 1982 verdict in the case of John Hinckley (who attempted the assassination of President Reagan), the American Psychiatric Association recognized PSRBs as a possible model for the management and treatment of NGRI acquittee patients.30 Connecticut followed suit, establish- ing its PSRB in 1985.31 Utah passed analogous legislation in 1989,32 and Arizona established its PSRB in 1994.33 ese states have what has been termed “external” review boards in that they have statutory authority over NGRI acquittees with regard to their release to the community, the monitor- ing of conditional releases (i.e., monitored treatment in the community), and, if necessary, the revocation of releases. However, other states, such as Maryland, have established

what have been referred to as “internal” review boards, with the intent to “continue judicial decision-making regarding release and revocation but seek improvement in the forensic hospital system’s performance in generating recommenda- tions to the courts.”34

Oregon’s PSRB has been written about most exten- sively, followed by Connecticut’s PSRB, which is similarly structured. Both states’ boards are made up of members appointed by their respective governors and con rmed by their legislative branches, such as an attorney, a psychia- trist, a psychologist, an individual knowledgeable about probation and parole, and lay citizens.35,36 In addition, Connecticut’s Board includes a lay citizen with victim advocacy experience.36 Connecticut’s Superior Court is responsible for committing acquittees to the Board for a speci c length of time related to the sentence that might have been imposed if criminally convicted, which in turn mandates the appropriate level of supervision. e Board also recommends the treatment conditions under which an acquittee may return to the community and advises the Superior Court as to whom it deems as meeting criteria for continued commitment versus discharge from the Board.36

e US Supreme Court held in Jackson v. Indiana37 that “due process requires that the nature and duration of commitment bear some reasonable relation to the purpose for which the individual is committed.” In Jones v. US,38 the US Supreme Court held that states have the right to commit a person found NGRI for an inde nite period as long as the individual remains mentally ill and dangerous. In both Oregon and Connecticut, in order for insanity acquittees to remain under the Board’s jurisdiction, they must continue to be a danger to self or others because of a psychiatric disability.39,40 In Oregon, once the maximum time that could have been served had there been a convic- tion is reached, the individual must either be discharged or civilly committed. However, in Connecticut, if “rea- sonable cause exists to believe that the acquittee remains a person with psychiatric disabilities or a person with intel- lectual disability to the extent that his discharge at the expiration of his maximum term of commitment would constitute a danger to himself or others, the state’s attor- ney can petition the court for an extended commitment” under the Board.40

ere has been some pushback and debate about how security-conscious PSRBs should be in their commitment of insanity acquittees and how much power they should possess, speci cally regarding their ability to recommit end-of-term acquittees past the maximum time that could have been served had they been found guilty of the involved o ense.41 Olmstead v. L. C. by Zimring,42 a US Supreme


Court case dealing with institutionalized disabled persons and the need to o er community-based treatment pro- grams for those who quali ed, has been applied to how long and where insanity acquittee patients are held and treated. It becomes a collaborative process between the hospital sta and outpatient providers to devise a treatment plan that maximizes patients’ chances of remaining safe and out of the hospital, although with PSRB oversight.

Once it is recommended that NGRI patients transi- tion back into the community, as noted earlier, the process is gradual, beginning with temporary leaves from the hos- pital of a few hours and progressing to include overnight leaves. During this process, acquittees begin to engage with community providers. At the point where it is determined that an acquittee patient is ready for conditional release to the community, their care is transferred to community providers who agree to follow the patient’s individualized conditional release plan, which can include such provisions as continued treatment of sexual and substance abuse disor- ders. In addition, the provider agrees to periodically report to the PSRB regarding treatment progress and any changes in the acquittee patient’s mental condition. Finding willing and quali ed treatment providers can be di cult because there is o en a reluctance to take these patients into treat- ment. Oregon provided state funding for such treatment, but Connecticut did not, forcing state facilities to provide treatment rather than the private sector. Also, in addition to providing treatment, community providers are mandated to supervise the acquittee and report any violations of release conditions. As with patients on probation, this mandate can create a di cult treatment relationship. For example, the provider maybe involved with visits to the patient’s resi- dence and be called to report violations such as nding a can of beer in the patient’s refrigerator. Again, as noted ear- lier, the PSRB continues to closely monitor the treatment and supervision of these patients, just as it did when they were maintained in a hospital setting. At any point, the PSRB may remand the patient back to the hospital for re- evaluation if they are deemed nonadherent to the speci ed conditions of their conditional release plan.

Because the PSRB’s prime objective is protecting the public from dangerous insanity defense acquittees, condi- tional release plans are o en quite restrictive and conser- vative. In relation to the Oregon PSRB, some opined that it was risk-adverse in the management of insanity defense acquittees.43 In response to this concern, the PSRB recently underwent a restructuring to limit its scope and power, and the insanity defense is open only to those facing felony charges or those already hospitalized insanity acquittees who have committed serious crimes.43

Attempting to balance the rights and treatment of indi- vidual insanity acquittee patients against the equally impor- tant task of protecting the public is di cult. Mental health professionals are mandated to maintain safety in the least restrictive treatment settings available44 and to do so by making predictions regarding someone’s future dangerous- ness. is task is challenging and sometimes unsuccessful,45 but mental health professionals are currently obligated to perform it to the best of their abilities.


Potentially dangerous patients are found in all public-sector treatment settings, and clinicians o en struggle with how best to manage them. Forensic psychiatrists can play an important role in consulting with clinicians working with patients who are at a heightened risk for committing dan- gerous acts and providing education about risk manage- ment. ese consultations can take many forms: regular risk management meetings, informal consultations on an as-needed basis, didactic sessions, and formal consultations with written reports. Regardless of the format, the goal is to enhance the capability of all clinicians in the mental health system to assess and manage patients at high risk for violence.

Since its inception, the eld of violence risk assess- ment has undergone several important advancements. In Barefoot v. Estelle,46 a landmark US Supreme Court case, the American Psychiatric Association wrote an amicus brief noting that psychiatrists were not particularly skilled at identifying those at risk for violence and cited that, using clinical judgment alone, psychiatrists were wrong about predictions of risk in two out of three cases. Following this decision, psychiatrists and psychologists dedicated them- selves to improving the science of risk assessment. Many new tools were developed, and these are discussed herein.


Actuarial instruments were created to assist clinicians by identifying patients who are at high risk for committing violent acts, both physical and sexual. ese instruments typically use static factors alone, historical information that shows little to no change over time, such as whether an adult being assessed experienced behavioral problems as an ado- lescent. In an attempt to nd variables that both predict risk and are amenable to change through treatment, researchers


have recently focused on the inclusion of dynamic factors into actuarial tools. Dynamic factors are those that show a greater degree of change over time, such as impulsiveness or a negative mood. To date, however, studies have not validated a dynamic variable that is correlated to a parallel change in risk with a degree of sensitivity and sensitivity that is clinically useful.47

Examples of static risk assessment tools are the Rapid Risk Assessment for Sex O ense Recidivism (RRASOR)48 and Violence Risk Assessment Guide (VRAG).49 e RRASOR asks four questions and then estimates the like- lihood of a reconviction for a sexual o ense over a 5- and 10-year time frame. e VRAG is a more complicated instrument that requires a detailed review of the subject’s history and also incorporates scores from another actuarial instrument, the Psychopathy Checklist-Revised (PCL-R), which uses some dynamic factors and is discussed later in this section. e score from the VRAG then estimates the probability of violent recidivism at 7- and 10-year intervals.

Actuarial tools have both inherent bene ts and fun- damental aws when used in clinical practice. e princi- pal bene t is that the examiner is o en required to collect detailed information on the subject’s past criminal con- duct and psychiatric history. is helps the examiner bet- ter understand the subject of his or her assessment, which should inevitably enhance the management of risk. ese tools may also be useful for courts when considering the potential for future long-term risk to the community and in research when evaluating large populations.

However, risk predictions from actuarial tools are o en not useful in clinical situations where immediate decisions are demanded. By their nature, actuarial risk assessment tools derive their data by collecting information from large groups of people. ese large groups are then subdivided based on a correlation between demographic factors and criminal recidivism. For example, the VRAG has nine sepa- rate subdivisions. e evaluator who completes the tool is essentially determining into what subset the subject of his or her assessment most closely ts. By doing this, there is a potential for inaccuracy due to the study group having sig- ni cant di erences from the individual being assessed, such as cultural di erences or the person’s placement in a highly restrictive setting that lessens his likelihood of o ending.

Further limitations of actuarial tools come from the nonspeci c predictions of recidivism. For example, you may evaluate a patient using the VRAG and determine that the individual receives a score consistent with a probabil- ity of violent recidivism at 7 years of 44% and at 10 years of 58%. is test does not tell you whether the individual falls within the 56% of individuals who, in 7 years, will not

have committed a violent crime. Furthermore, if the subject of your evaluation happens to fall in the violent 44%, this instrument will not tell you anything about who will be the subject of violence, the degree of violence, or exactly when during that 7-year time frame the violent act will be com- mitted. Based on these limitations, there is little practical information available to psychiatrists trying to determine whether this individual should be admitted to the hospital or released into the community.

From a research perspective, there are high hurdles to overcome when developing an actuarial tool. What clini- cians primarily seek from an actuarial tool is the ability to predict when a highly violent event will occur, such as a sexual assault, murder, or suicide. ese are very low- frequency events, termed low base rate events, in the gen- eral population, and they therefore either require a very large study group for a prospective analysis or the selection of a targeted sample, such as a prison population, for a ret- rospective analysis. Unfortunately, retrospective analyses tend to bias ndings, and the use of such information to predict future behaviors in the general population is o en inaccurate.

Another hurdle in predicting behaviors that have a low base rate involves speci city and sensitivity. Finding a tool that has both a high true-positive rate (speci city) and a high true-negative rate (sensitivity) is mathematically daunting. Szmukler of King’s College London50 points out how low base rates sap the accuracy of tools to predict vio- lent behaviors. Using a hypothetical tool that has a sensitiv- ity and speci city of 0.7 and 0.7, which is considered high, he calculates that with a 20% base rate for the criminal con- duct being predicted, the tool would be wrong 6 out of 10 times. For highly violent crimes or acts where the base rate is 1% (which is itself a high estimate), the “positive predictive value” of this same test drops to 0.03, meaning that the tool would predict wrongly 97 times out of 100.


Another tool used in the consideration of risk is the PCL- R51 developed by Robert Hare. is tool attempts to catego- rize elements in an individual’s personality consistent with psychopathy. Although psychopathy is not a personality disorder de ned in the Diagnostic and Statistical Manual of Mental Disorders (DSM 5), this term is o en discussed in the context of risk assessments. Patrick52 writes about the personality of an individual with psychopathy as including varying degrees of meanness, disinhibition, and boldness. Alternatively, Hare53 describes psychopaths as “social preda- tors who charm, manipulate, and ruthlessly plow their way


through life, leaving a broad trail of broken hearts, shattered expectations, and empty wallets.”

e PCL-R is a tool that looks at both static and dynamic factors in an individual and determines the rela- tive level of psychopathy compared to control groups. e instrument has been widely studied and validated for cor- rectional inmates, patients in forensic hospital settings, juveniles at community detention facilities, and sex o end- ers.54 e PCL-R has long been considered the gold stan- dard55 when evaluating an individual for psychopathy. e administration of this assessment tool must be performed by a trained and quali ed clinician and involves a review of an individual’s past criminal conduct including police reports, an interview with a collateral source such as a family member who knows the subject well, and a semi-structured interview with the subject of evaluation.

A er completing this extensive evaluation, the clinician then sums totals from 20 di erent factors, with responses ranging from 0 to 2. ese factors assess interpersonal, a ective, lifestyle, and antisocial traits possessed by the subject. If the individual scores 30 or higher, he or she con- sidered to meet criteria established for psychopathy. Scores on the PCL-R do not directly calculate criminal recidi- vism rates. e e ect of this assessment is essentially to give clinicians an indication of their patient’s tendency to display traits of psychopathy, which is itself a risk factor for violence. e score from the PCL-R alone is not a suf- cient basis to make a determination as to whether an indi- vidual should be hospitalized or can be safely released to the community.


Many dozens of studies have now been performed to cor- relate mental health and demographic factors with violence risk. Many, but not all, studies show a higher rate of vio- lent behavior among individuals with SMI. However, when individuals with SMI are compared with others in their community, rather than with the population as a whole, the relative rates of violence show much less of a di erence. Based on the current research, the following conclusions can reasonably be drawn about the correlates for violence56:

• Substance abuse, both alone and in combination with a mental disorder, is consistently correlated with violence.

• Sociodemographic factors (male gender, young age, low educational level, and low socioeconomic status) are strongly correlated with violence.

• Mental disorders are moderately correlated with violence but less so than either substance abuse or sociodemographic factors.

• Medication compliance in persons with SMI correlates with decreased rates of violence compared to those who are not compliant.57

In general, substance abuse and sociodemographic fac- tors are more strongly predictive of violence than is mental illness. In one major study, the added risk of violence from psychosis was small; close family members and friends were the most frequent targets of violence.57 Despite widespread media portrayals, persons with SMI are not likely to target strangers in public, and they are much more likely to be vic- tims of violence than perpetrators.11


Clinical assessment, informed by evidence-based violence risk factors (outlined later), is the technique most utilized by psychiatrists to make decisions about dangerousness. In this approach, the clinician applies his or her knowl- edge of the literature and assessment skills to determine risk in a particular patient. Although this method, termed research-informed clinical risk assessment, does not have superior statistical accuracy to actuarial tools, the technique remains helpful to clinicians because these assessments focus directly on the patient’s clinical need and treatment plan. Conclusions in these evaluations typically categorize individuals into ranges of risk, such as high, moderate, or low. Such evaluations give clinicians a reasoned basis for their clinical conclusions and justi cations for interven- tions such involuntary hospitalization. Several studies have shown greater-than-chance validity for clinically based risk assessments.58 When employing this technique, it is impor- tant for clinicians to remain current in their knowledge about violence risk factors because the science is continu- ally evolving.

In addition to identifying demographic or historical risk factors for violence, clinical assessment of violence risk should also include an assessment of pathways to dan- gerousness for a given patient. Although many individuals may have committed similar violent acts—homicide, for example—their motivations for engaging in the act are based on highly individualized factors. e judicial system has long acknowledged this individual distinction, not- ing that a crime requires both a guilty act (actus reus) and a guilty mind (mens rea). In managing risk and predicting


dangerousness, it is important for clinicians to determine what drives violence in an individual. In the case of a per- son with schizophrenia who has a history of striking people when psychotic, a reasonable intervention to mitigate risk is to assure treatment compliance and perform routine men- tal status assessments. For an individual with schizophrenia who also has clear psychopathic traits and engages in vio- lence to intimidate others, the intervention to reduce risk may not rest in the realm of medication compliance, and it may not be best managed in a mental health setting.


Risk is a broad term that refers to the chance of an injury, damage, or loss. Although risk o en refers to the danger a patient may pose to others, it may also include the danger a patient poses to himself or to property. Risk is further used in the discussion of legal liability regarding the potential fallout from a bad outcome in a challenging clinical situa- tion. us, when asking for a risk assessment, it is important for the clinician to specify the type of risk being assessed and to formulate a consultation question.

O en, the clinician’s question for the forensic con- sultant is whether or not the patient presents a risk to the community. With such a broad question, the answer o en begins with, “It depends … ,” and has little practical or clinical usefulness.

When considering a consultation question for a foren- sic psychiatrist, the clinician should think in terms of how the identi ed risk should be managed, which is why such consultations are more o en referred to as a risk manage- ment consultation rather than a risk assessment. With this approach, the expertise of the forensic psychiatrist is directed to collaborating with the treatment team to safely manage the patient rather than simply describe the patient in terms of his or her risk of dangerousness.

Although a useful question may be “Under what com- munity treatment would the patient pose the least risk?” an even more useful and practical consultation occurs if the provider rst proposes a speci c management plan for the patient and then asks for a risk management consulta- tion based on that plan. e forensic psychiatrist can then address the details of that plan, the safety of the various ele- ments of the plan, and what portions of the plan require revision. At that point the team is in a position to immedi- ately o er clinical options leading directly toward a practi- cal solution for the patient.

Psychiatrists in the public sector make risk management decisions on a daily basis. Obtaining consultation on each

occasion when risk is considered is impractical and o en adds limited clinical value. As risk appears to become more imminent, or the potential magnitude for dangerousness rises, the clinician should begin to consider a consultation. A rst step is to consult a colleague or another member of the team. However, when the concerns for risk heighten beyond the experience or expertise of those readily avail- able, then requesting a consultation from a forensic psychia- trist is indicated.

Circumstances warranting a risk management consul- tation occur in numerous clinical and medical/legal situa- tions. Examples include:

• When the risk of harm to others is considered substantial and how to manage the case is a point of contention among the team.

• Situations when it is important to have a psychiatrist experienced with the interpretation of state or federal statutes.

• When an independent second opinion is considered necessary from a liability perspective.

• When a case involves a potentially high-pro le situation.

• When testimony is required, such as for probate court, and the treating psychiatrist determines that giving testimony may negatively impact the treatment alliance.

• When the inpatient facility feels the patient is ready for discharge and the outpatient treatment team disagrees. ese situations are o en related to resources need to treat rather than disagreements about actual risk.
Psychiatrists will enhance their ability to manage danger- ous clinical situations by systematically reviewing factors contributing to risk and designing a treatment plan to address each factor. Common clinical factors that sug- gest a heightened risk for dangerousness are identi ed in Table 8.1.
When considering the potential for future dangerous- ness, the examining psychiatrist should carefully review each past incident of violence, including self-harm, and assess what factors contributed to that action. By doing this, the clinician can then better determine which factors are more likely to predict dangerousness in the future.
e requesting clinician is also in a position to request how the forensic consultant’s ndings should be reported. e requesting clinician should specify whether a verbal



Based on these elements, the primary burden of the psychiatrist is to ful ll her duty to the patient. Speci cally, the duty is to provide a reasonable standard of care to the patient. e duty of the psychiatrist is not to prevent all harm from occurring in the situation or to accurately pre- dict the future, but rather to perform a proper assessment and institute treatment that represents a reasonable stan- dard of care. In this example, if the patient is released and fatally harms his spouse, the psychiatrist may not be found liable for malpractice if a proper assessment and manage- ment plan was put into place, despite the tragic outcome.

In this example, using an actuarial tool to assess risk will have limited clinical usefulness, in part because the psychia- trist is asked to make a decision about risk in the short term. Using the clinical approach, a proper risk management assessment would be for the psychiatrist to:

1. Conduct a thorough psychiatric assessment of the patient.

2. With a valid release of information, obtain collateral records including past psychiatric treatment, substance abuse treatment, and criminal history (many states allow access to convictions on the Internet).

3. oroughly review with the patient his view of the violent incident and events leading up to the incident.

4. Attempt to obtain a police report for the criminal incident. e patient’s lawyer may be helpful in this regard.

5. Although it may not always be appropriate to contact the victim, in this case, the victim elected to stay involved, so contacting that person to discuss the patient’s history and her view of violent incident is reasonable and bene cial. A release of information from the patient is not required if information is only being obtained, but because these discussions o en involve disclosures of clinical information, a valid release of information is strongly encouraged.

6. Contact the hospital attorney to determine if the court has any hold on the patient that would necessitate
his return to the judicial or correctional system if discharged from the hospital.
Data collected from these sources will allow the psy-

chiatrist to either formulate a plan for discharge that meets a reasonable standard of care or better justify the patient’s need for continued inpatient treatment. e plan should address the patient’s need for treatment and monitoring of compliance, support the spousal relationship in managing future con icts, provide interventions to lessen the likeli- hood for future recurrences of violence (such as removal of


Prior violent acts Suicide attempts

Self-mutilating behaviors

History of elopement

History of treatment noncompliance62

Past substance abuse63 History of re setting

History of sexually o ending behaviors


Homicidal or suicidal ideation

Delusions, especially threat/ control/override themes59,60

Command hallucinations to act in harmful ways61

Poor coping skills

Recent severe disruption in the patient’s life

Unstable living environment64, 65 Ongoing con icts with others Substance abuse/intoxication


response is all that is needed or if a more formal written consultation is necessary. Typically, a written consultation is the preferred means of communication because this will provide important documentation for the provider’s future treatment rationale.

An example of a typical risk management consultation:

A middle-aged man with suicidal ideation was recently psychiatrically hospitalized a er an inci- dent of domestic violence. e patient was charged with assault and released from court to the hospi- tal without bond. His next court date is not for a month. e patient is diagnosed with major depres- sion and an alcohol use disorder. He has no history of suicide attempts or psychiatric treatment and is no longer suicidal. e patient’s spouse wants him to return home, and there is no restraining order. e treatment team is uncertain about the safety of this discharge plan.

is case represents several areas of concern: risk to self, risk to others, and the legal liability of the psychiatrist who approves the discharge plan. In addition to the ethical and moral obligations a physician holds, it is important for the psychiatrist to appreciate the elements of malpractice. ese elements are that the physician has a duty to provide proper care and treatment to her patient. If there is a derelic- tion of that duty, damages result, and it is determined that there is a proximate cause between the dereliction of duty and the damages, liability for these damages may fall on the physician.


weapons or alcohol from the home), and provide a resource for the patient and his spouse to immediately contact in the event that their relationship deteriorates.

e daily challenges confronting the public psychia- trist can be daunting, but they can be made manageable by employing techniques to identify at-risk patients and using a structured process to manage the risk. Doing so will help clinicians to provide better care to his or her patients. Although risk (and the psychiatrist’s worry) can never be eliminated, it can be substantially reduced with knowl- edge about violence risk and appropriate consultation with forensic professionals.


As a result of legal and policy changes in the latter half of the 20th century, forensic psychiatry and public-sector psychiatry have become increasingly connected. e two disciplines now collaborate in managing individuals with SMI and histories of violence because private treatment settings o en lack the expertise or resources to work with these challenging patients. Forensic patients are managed in several public sector settings: secure hospitals, prisons and jails, and outpatient programs. Because of their expertise in violence assessment and risk management, forensic psy- chiatrists can play an integral role in all of these settings. In addition, all public-sector psychiatrists must become famil- iar with some aspects of forensic psychiatry, particularly the assessment and management of violence risk. With a basic understanding of actuarial and clinical risk management tools, psychiatrists can better care for these complex and challenging patients.


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64. Mulvey EP, Lidz CW. Clinical considerations in the predic- tion of dangerousness in mental patients. Clin Psychol Rev. 1984;4:379–401.

65. Swanson JW, Swartz MS, Meador KG. e social-environmental context of violent behavior in persons treated for severe mental ill- ness. Am J Pub Health. 2002;92:1523–1531.






omas J. McMahon, Nakia M. Hamlett, Christy L. Olezeski, Timothy C. Van Deusen, Natasha Harris, and Doreen J. Flanigan


Amid calls for a comprehensive, continuous, coordinated, compassionate, and culturally competent system of health care that is developmentally informed and technically sophisticated,1 children and adolescents usually receive health care services from professionals in a pediatric sys- tem located in one setting, and adults usually receive health care services from professionals in an adult system located in another setting. In public psychiatry, the system of care for children and adolescents exists relatively independent of the system of care for adults in ways that mirror di erences present throughout the health care system. Children and adolescents with serious emotional-behavioral di culty are typically treated in one system by professionals work- ing from one perspective, whereas adults with serious psy- chiatric di culty are typically treated in another system by professionals working from a somewhat di erent perspec- tive. Although there are similarities across the two systems, there are important di erences that should be outlined in any textbook for behavioral health professionals interested in public psychiatry. Consequently, this chapter provides an overview of the publicly funded system of care for children and adolescents experiencing serious emotional-behavioral di culty. Although professionals entering the system of care for children and adolescents may nd this summary helpful, the discussion focuses most clearly on the needs of professionals entering the system of care for adults. Educational highlights of this chapter and de nitions of key terms are outlined in Box 9.1.

When considered from an educational perspective, there are a number of reasons that adult clinicians should

have a basic understanding of developmental psychopathol- ogy and the publicly funded system of care for children and adolescents. First, epidemiologic research indicates that adult psychopathology tends to be characterized by devel- opmental precursors that rst become evident during child- hood or adolescence.2 Understanding adult clients from a developmental perspective can inform their assessment and treatment. Second, research on the nature of child and adolescent psychopathology o en informs understanding of adult psychopathology.2 Again, current understanding of developmental trajectories associated with speci c adult presentations can inform the di erential diagnosis of clients who appear similar when examined from a symptomatic perspective but may di er in important ways when exam- ined from a developmental perspective.

Moreover, many clients in the publicly funded system of care for adults have also been clients in the publicly funded system of care for children and adolescents. Understanding the pediatric system may help clinicians understand the pathway their clients took to their current position in the service delivery system. Next, adult clinicians may have to assist with the transition of adolescents from the pediatric to the adult system. Understanding the publicly funded system of care for children and adolescents will facilitate movement of clients into the publicly funded system of care for adults. Finally, many clients in the adult system are parents with children at risk for psychiatric di culty. Understanding the publicly funded system of care for chil- dren and adolescents will help clinicians support parents who have to seek services for their children and then work with other providers to coordinate services being provided to the family across the two systems.


Box 9.1

Educational Highlights

• Clinicians working in the publicly funded system of care for adults need to have a basic understanding of child and adolescent psychopathology and the publicly funded system of care for children and adolescents.

• Although the child study and child guidance movements served as the foundation of the publicly funded system of psychiatric treatment for children and adolescents, the concept of a system of care formally introduced in 1986 has in uenced the development of the publicly funded system of psychiatric treatment for children and adolescents for more than 25 years.

• e guiding principles supporting the development of the publicly funded system of care for children and adolescents dictate that psychiatric services and supports be (1) population-based, (2) developmentally oriented, (3) child-centered, (4) family- driven, (5) strength-based, (6) community-based, and (7) culturally sensitive. Within the publicly funded system of care, there is also an emphasis on (1) empirically based practice, (2) interdisciplinary treatment, and (3) interagency collaboration.

• e publicly funded system of care needs to consider ways to o er developmentally informed approaches to engagement and intervention designed to better support adolescents with serious psychiatric di culty as they make the transition from the pediatric to the adult system of care.

• e four traditional behavioral health disciplines of psychiatry, clinical psychology, nursing, and social work need to consider ways to recruit and train the next generation of professionals to further develop the publicly funded system of care for children, adolescents, and young adults.
Key Terms
roughout this chapter, the terms child, adolescent, and young adult are used to refer to an individual from birth to 11 years old, 12 to 17 years old, and 18 to approximately 25 years old. e term transitioning youth is used to refer to an individual 16 to approximately 25 years of age leaving the mental health, child welfare, juvenile justice, special education, or other system of care as eligibility for services expires.


Many historians believe that the origins of contemporary child psychiatry can be traced back to the child study and child guidance movements that began as the 1800s came to a close. Although remnants of both movements can be found in the publicly funded system of care for children and adolescents, the system has, over more than 100 years, been rede ned and reorganized by a number of other in u- ences. Other important in uences include (1) worldwide expansion of child psychoanalysis, (2) the introduction and expansion of Medicaid, (3) the community mental health movement, and (4) ideas about a system of care. e con- cept of a system of care for children and adolescents with serious emotional-behavioral di culty has, more than any- thing else, shaped the development of the publicly funded system of care. It is important to note, however, that some policy analysts3 have argued that the development of a comprehensive system of appropriate, accessible psychiat- ric services for children and adolescents has been slowed by the absence of a national policy on child mental health. ese critics complain that, rather than being directed by

a coherent, consistent national policy, the development of psychiatric services for children and adolescents has been driven by policy and program developments in the areas of social welfare, child welfare, special education, juvenile jus- tice, and adult mental health.


G. Stanley Hall, the rst president of Clark University and the rst president of the American Psychological Association, is frequently credited with starting the child study movement, which contributed to the evolution of developmental psychology, educational psychology, and child psychiatry.4 Directly in uenced by Hall, several pedia- tricians established child study centers throughout the coun- try to study normative child development.5 Arnold Gesell, for example, established the Clinic of Child Development within the Yale University School of Medicine in 1911, before completing his medical degree. Subsequently, nan- cial support from the Laura Spelman Rockefeller Memorial helped to establish a national network of child study cen- ters. e Iowa Child Welfare Research Station; the Institute of Child Welfare at the University of California, Berkeley; the Saint George School for Child Study at the University


of Toronto; the Institute for Child Development at the University of Minnesota; and the Child Welfare Institute at Teachers College, Columbia University were some other early child study centers.5 Although originally developed to promote the study of normative child development with the intent to generate empirical knowledge for use in the education of parents, teachers, and pediatricians, some of the early child study centers moved toward the study of aberrant development. As the focus of the research being done in child study centers linked with academic institu- tions shi ed over time, they gradually became important components of an early publicly funded system of care for children and adolescents.


Without dismissing the in uence of the child study move- ment, the publicly funded system of care for child and adolescents can also clearly be linked with the child guid- ance movement. Conceptually, the child study versus child guidance movements represented an early distinction between the medical tradition of studying normative and aberrant child development in an academic setting and the social work tradition of providing services to socially and economically disenfranchised individuals in a community setting. Many historians6 believe that the child guidance movement was grounded in the work of William Healy, who founded the Juvenile Psychopathic Institute in 1909. Concerned about juvenile delinquency in Chicago, a group of philanthropists opened what many people believe to be the rst child guidance clinic with a conceptual model of service delivery clearly grounded in a commitment to inter- disciplinary collaboration. In 1922, the Commonwealth Fund began its Program for the Prevention of Juvenile Delinquency that supported the development of child guidance clinics designed to provide preventive services to school-aged children of normal intelligence exhibiting behavioral di culty.6

From the beginning, the child guidance movement drew on the values of social work and clinical psychology, and the medical control of the child guidance clinics was actively resisted.6 Over years, the original goal of prevent- ing juvenile delinquency waned, and child guidance clinics became outpatient treatment programs for children and adolescents experiencing psychiatric di culty.6 Although the early child guidance clinics provided services to low- income families on a sliding-fee basis, there was no clear mechanism to ensure that child guidance services were widely available and easily a ordable. With public support, the extensive network of child guidance clinics established

before 1960 did, however, eventually become a cornerstone of the publicly funded system of care for children and ado- lescents.6 Although a sensitive issue with historical evidence of battles over professional turf,7 the child guidance move- ment, more than anything else, advanced the idea of an interdisciplinary approach to the assessment and treatment of children and adolescents experiencing serious emotional- behavioral di culty.


Both the child study and child guidance movements of the early 1900s were also in uenced by the introduction of child psychoanalysis. Psychoanalytic work with children began in 1909, when Sigmund Freud summarized his consultation with the father of a little boy su ering with an irrational fear of horses that Freud interpreted using his theory of the Oedipus complex.8,9 Child psychoanalysis then emerged as an extension of adult psychoanalysis advanced by Anna Freud, Melanie Klein, Margaret Mahler, Edith Jacobson, Erik Erikson, and Donald Winnicott.8,9 Anna Freud and Melanie Klein developed the two most prominent schools of thought on child psychoanalysis and engaged in rigor- ous debate about the speci cs of their approaches during a series of meetings sponsored by the British Psychoanalytical Society between October 1942 and February 1944.8 Anna Freud also helped to open the Hampstead War Nursery in London and then the Hampstead Child erapy Course and Clinic following the end of World War II. Historians10,11 o en identify the Hampstead Child erapy Course and Clinic as the rst psychoanalytic institute devoted exclu- sively to research, training, and treatment being pursued with children. Much of the work done in the nursery and the clinic focused on the needs of children a ected by World War II.10,11 A er her death, the Hampstead Child erapy Course and Clinic was renamed the Anna Freud Centre, and the center continues to serve low-income chil- dren and adolescents with links to the publicly funded sys- tem of care in the United Kingdom.11

As the child psychoanalytic movement expanded, ser- vice delivery within child guidance clinics in North America and Europe began to integrate ideas outlined in the psycho- analytic literature on children and adolescents.12 Building on the early work of Anna Freud, child guidance clinics became more enthusiastic about understanding psychopa- thology as deviance from normative development, and the concept of a developmental diagnosis became popular.9 Likewise, the concepts of a holding environment, a tran- sitional object, and good-enough mothering outlined by Donald Winnicott; the concept of separation-individuation


presented by Margaret Mahler; and ideas about attachment advanced by John Bowlby became in uential.9 Consistent with child psychoanalysis, child guidance clinics also began to emphasize the use of close observation in the clinical assessment and the use of play in treatment.9 e empha- sis on the developmental sequelae of early psychological trauma, the emphasis on early intervention with infants and preschool children, and the concept of collateral inter- vention with parents were also integrated into the evolving publicly funded system of care.9


Although the nal report called for the continued devel- opment of psychiatric clinics for children and adoles- cents, the rst major public policy initiative outlined by the Joint Commission on Mental Health and Illness,13 in 1961, focused largely on the needs of adults, and there was early debate about whether child guidance services should be located within a community mental health center.14 Consequently, the subsequent funding of community men- tal health centers did not have a dramatic impact on the publicly funded system of care for children and adolescents.3 Part F of the Mental Retardation Facilities and Community Mental Health Center Construction Act did, however, include funding for special projects designed to better meet the needs of children and adolescents.3,15 With the success of these demonstration projects, the government required that community mental health centers o er services to children and adolescents on a limited basis.15 Despite these early e orts, a general lack of attention to the needs of chil- dren and adolescents during the early community mental health movement led to a report by the Joint Commission on the Mental Health of Children titled, Crisis in Child Mental Health.16 e nal report of the commission did not result in a national policy or program, but it did articulate the principles of child advocacy that became the basis for the articulation of the concept of a system of care.

Some 10 years later, the Mental Health Systems Act of 1981 that was passed during the Carter Administration with intent to continue nancing of community mental health centers listed children and adolescents with serious emotional-behavioral di culty as an underserved popula- tion deserving special attention, but the act was repealed by the Reagan Administration before it was implemented.3 Block grant funding of psychiatric and substance abuse ser- vices during the Reagan Administration reduced funding to the states, but the process eventually required that the states set aside a certain percentage of block grant funding for psychiatric services designed to better meet the needs of

children and adolescents.3 As federal nancing for commu- nity mental health declined, the states did not provide com- munity mental health centers with the funding necessary to support special programming, and services for children and adolescents disappeared from many community mental health centers.


Although the community mental health movement did not have a dramatic impact on the publicly funded system of care for children and adolescents, simultaneous passage of the Social Security Amendments of 1965 did have a dra- matic impact by creating Medicaid.17 By matching state funding for health care with federal funds, Medicaid dra- matically expanded access to health care for children living in low-income families. It also included a formal mandate that the states o er psychiatric services, including psychi- atric services for children and adolescents. A er Medicaid was operated on a fee-for-service basis for several decades, active management of Medicaid bene ts during the 1990s dramatically reduced utilization of inpatient resources and dramatically increased the development and utilization of intensive outpatient programs and other alternatives to inpatient hospitalization.18 Its impact on the utilization of outpatient services was equivocal.

e State Children’s Health Improvement Plan that was introduced in 1997 increased access to health care for children living in low-income families by expanding eligi- bility for Medicaid and retaining an expectation that, with quali cation, bene t plans include provisions for psychiat- ric services.18 Historically, approximately 33% of Medicaid recipients who receive psychiatric services are children and adolescents.19 Children in foster care and children with seri- ous developmental di culty account for a disproportion- ate percent of Medicaid spending on psychiatric services, and the largest portion of Medicaid funds spent on psy- chiatric services supports outpatient treatment.20 Although Medicaid may have dramatically increased access to services for children and adolescents experiencing serious emotional- behavior di culty, low rates of Medicaid reimbursement for psychiatric services probably contributed, over time, to the separation of the public and private systems of care.


In 1982, Jane Knitzer21 highlighted the need for a national system of psychiatric services for children and adolescents in a report commissioned by the Children’s Defense Fund. Following publication of her report, the National Institute


of Mental Health initiated the Child and Adolescent Service System Program that provided nancial and tech- nical assistance for the development of systems of care for children and adolescents with psychiatric di culty.3 From the beginning, the initiative recognized that children and adolescents with serious emotional-behavioral di culty are o en involved with several service delivery systems such that planning for e ective intervention requires interagency collaboration. In 1986, Beth Stroul and Robert Friedman22 formally and broadly de ned a system of care as a compre- hensive continuum of services and supports organized into a coordinated network to meet the complex needs of chil- dren and adolescents with psychiatric di culty, and they began to outline a set of principles to guide the develop- ment of local systems of care for children and adolescents experiencing serious emotional-behavioral di culty.

In 1992, Congress passed legislation creating the Comprehensive Community Mental Health Services for Children and eir Families Program to provide funding to build systems of care. Today, the program continues to be an important source of federal funding to support the development of a comprehensive array of community- based services grounded in the concept of a system of care.23 Over more than 25 years, the concept of a system of care for children and adolescents has evolved,24–28 and it served as the basis for many of the recommendations made by the Subcommittee on Children and Families for the New Freedom Commission on Mental Health.29 Although debate about the most appropriate de nition of the concept continues,30 Stroul, Blau, and Friedman31 last updated it by de ning a system of care as a broad array of community-based services and supports orga- nized into a coordinated network to help children and adolescents with serious emotional-behavioral di culty function better at home, in school, and in the commu- nity. As implementation of the Patient Protection and A ordable Care Act and the Health Care and Education Reconciliation Act of 2010 (ACA) continues, policy ana- lysts32 have begun to explore ways that health care reform may in uence further development of the concept of a system of care for children and adolescents with psychi- atric di culty.


As noted earlier, the concept of a system of care rst out- lined by Stroul and Friedman22 continues, more than

anythingelse,toin uencethedevelopmentofthepublicly funded system of care for children and adolescents. Within the federal government, the Child, Adolescent, and Family Branch of the Center for Mental Health Services within the Substance Abuse and Mental Health Services Administration (SAMHSA) supports ongoing develop- ment of the publicly funded system. However, many policy analysts and child advocates33–35 believe that the develop- ment of e ective systems of care occurs largely at the state, county, tribal, and local level. Consequently, the Center for Mental Health Services sponsors a National Technical Assistance Center for Children’s Mental Health36 that strives to sustain, expand, and improve local systems of care for children and adolescents experiencing serious emotional-behavioral di culty. e guiding principles that have directed development of the publicly funded system of care over more than 25 years are outlined in Table 9.1. As noted, these guiding principles dictate that psychiatric services and supports be (1) population-based, (2) child- centered, (3) developmentally oriented, (4) family-driven, (5) strength-based, (6) community-based, (7) mini- mally restrictive, and (8) culturally sensitive. Within the publicly funded system of care, there is also an emphasis placed on (1) empirically based practice, (2) interdisci- plinary collaboration, (3) interagency collaboration, and (4) accountability.


Epidemiological data suggest that, across technologically oriented cultures, 10–15% of children meet diagnostic criteria for a lifetime episode of psychiatric di culty, with evidence that there is a degree of speci city and consistency in the presence of speci c signs and symptoms over time, particularly for girls.37–39 By adolescence, 20–25% of teens meet diagnostic criteria for a lifetime episode of psychiatric di culty.40 Much of this psychopathology represents devel- opmental precursors of serious and persistent psychiatric di culty as an adult,2 and policy analysts41 argue that psy- chiatric disorders are among the most frequently occurring and most costly of pediatric health problems. Consistent with this, the National Research Council and Institute of Medicine42 estimate that psychiatric di culty in children and adolescents costs more than $250 billion annually. is estimate is, however, complicated by the fact that, despite national attention to the publicly funded system of care for children and adolescents, most children with serious




Population-based Child-centered

Developmentally oriented

Family-oriented Strength-based Community-based Minimally restrictive Empirically based Culturally sensitive

Interdisciplinary collaboration

Interagency collaboration Accountability


Services and supports for children and adolescents with serious emotional-behavioral di culty should be grounded in a thorough understanding of the target population.

Services and supports for children and adolescents with serious emotional-behavioral di culty should be con gured and delivered to meet the unique needs of each child or adolescent.

Services and supports for children and adolescents with serious emotional-behavioral di culty should be designed, developed, and delivered with intent to promote normative child development.

Services and supports for children and adolescents with serious emotional-behavioral di culty should allow for active participation of family in all aspects of service delivery.

Services and supports for children and adolescents with serious emotional-behavioral di culty should be designed, developed, and delivered to draw upon strengths present in the child, family, and community.

Services and supports for children and adolescents with serious emotional-behavioral di culty should be designed, developed, and delivered in a community setting.

Services and supports for children and adolescents with serious emotional-behavioral di culty should be o ered in the least restrictive setting possible.

e design, development, and delivery of services and supports for children and adolescents with serious emotional-behavioral di culty should be grounded in the best available empirical evidence.

Services and supports for children and adolescents with serious emotional-behavioral di culty should be designed, developed, and delivered in ways that promote sensitivity to the needs of all segments of the target population and minimize risk for discrimination against any segment of that population.

e administration and delivery of services and supports for children and adolescents with serious emotional- behavioral di culty should promote interdisciplinary collaboration with professionals with di erent expertise working cooperatively with one another to better meet the needs of children and adolescents.

Services and supports for children and adolescents with serious emotional-behavioral di culty should be designed, developed, and delivered in ways that promote coordination and collaboration across organizations serving the diverse needs of children and adolescents.

e performance of systems, organizations, and clinicians providing services and supports to children and ado- lescents with serious emotional-behavioral di culty should be evaluated to provide data that inform a process of continuous quality improvement.


Note. is list of guiding principles was extracted from the evolving literature on the concept of a system of care for children and adolescents with serious emotional- behavioral di culty.22–31

emotional-behavioral di culty do not receive adequate services.43,44

Data from the Comprehensive Community Mental Health Services for Children and eir Families Program23 and similar federal initiatives characterize, better than most sources of information, the children and adolescents being served in the publicly funded system of care. ese data suggest that almost all children and adolescents receiving services in the publicly funded system of care are living in low-income settings. Approximately 60% of the children and adolescents receiving services are living in urban or rural poverty. Almost all the children and adolescents enter- ing the publicly funded system of care are in the custody of a biological parent or other biological relative, but, relative

to the general population, children and adolescents in the legal custody of both biological parents are dramatically underrepresented. Approximately 50% of the children and adolescents are in the custody of their biological mother. Up to 85% of the children and adolescents begin services with a family history of psychiatric and substance use prob- lems. A family history of depression or substance abuse is very common. Unemployment among their parents is also relatively common.

Data collected from this federally funded system-of- care initiative23 suggest that, relative to their distribution in the general population, boys tend to be overrepresented throughout the publicly funded system of care. Likewise, children of African American, Hispanic, and Native


American heritage are usually also overrepresented, but they are still underserved. Children of European and Asian heritage are usually underrepresented. Undoubtedly a consequence of the criteria for admission, children aged 6–15 years tend to be overrepresented in the publicly funded system of care, whereas infants and preschool children, along with transitioning youth, tend to be underrepresented.

Data collected from this federal initiative23 also indicate that children and adolescents entering the publicly funded system of care present with signi cant exposure to psycho- logical trauma and family adversity. ey average four to seven traumatic life events. Emotional, physical, and sexual abuse is common. Exposure to physical, emotional, edu- cational, and medical neglect tends to be even more com- mon. Diagnostically, they present with varying patterns of both internalizing and externalizing di culty. Internalizing di culty in the form of anxiety, depression, and somati- zation is common. Externalizing di culty in the form of angry a ect, oppositional-de ant behavior, hyperactivity, aggressive behavior, and conduct problems is equally com- mon. Some data suggest externalizing di culty may be more common, but there does not appear to be consensus about the predominance of externalizing over internalizing di culty. Children and adolescents presenting with a mix of internalizing and externalizing di culty may actually be most common. Although not represented in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders,45 some scholars46 argue that the mix of internalizing and externalizing di culty common among children and adolescents entering the publicly funded sys- tem of care can be best understood as the consequence of repeated exposure to interpersonal trauma.

Looking beyond internalizing versus externalizing pathology, federal data28 also suggest that a history of

suicidal thoughts, deliberate self-harm, and suicidal behav- ior is common among children and adolescents entering the publicly funded system of care. Problems with school attendance, academic performance, and classroom behav- ior are also common. Although most typically present with low average to average intelligence, children and adoles- cents with attentional problems, speci c learning problems, intellectual disability, and autism spectrum disorders are disproportionately represented in the publicly funded sys- tem of care. Running away, substance use, and early sexual activity are not unusual among the adolescents. Children and adolescents entering this system also present with dis- proportionately higher rates of asthma, allergy, and obesity. A minority present with other serious medical problems.

Finally, children and adolescents entering the pub- licly funded system of care are usually involved with other publicly funded systems of care. For example, up to 40% of the children and adolescents may be involved with the child welfare system, up to 35% may be involved with the special education system, and up to 30% may be involved with the juvenile justice system.47,48 Although children and adolescents entering this system are frequently involved with other service delivery systems, policy analysts47,48 argue that rates of engagement in psychiatric services are actually still lower than the documented need among children and adolescents engaged with the child welfare, juvenile justice, and special education systems. at is, although children and adolescents seeking psychiatric services are frequently involved with these other service delivery systems, a sub- stantial segment of children and adolescents involved with those systems have a need for psychiatric services that is not being met. e clinical vignettes presented in Box 9.2 illustrate citionalized presentations of children and ado- lescents entering the publicly funded system of care.

Box 9.2

Jennifer and Robert (Bobbie) were a pair of siblings born to the same mother but di erent fathers. ey were referred to the child and adolescent service at a small community mental health clinic by their protective services worker shortly a er they were removed from the care of their biological mother because of concern about persistent physical, educational, and medical neglect.

Jennifer was an 8-year-old, Caucasian girl of Italian heritage. At the time of her admission, she was living in North Somewhere, Connecticut, with her therapeutic foster parents. Prior to this therapeutic foster placement, she had two brief, unsuccessful foster placements with extended family. She was attending Main Street Elementary School as a third-grade student assigned to a main- stream classroom with social work support. Presenting problems included depressed mood, anxiety about separation from her mother and older brother, preoccupation with her return home, suicidal threats, and aggressive outbursts at home and in school. A er having attended school sporadically for several years, she was socially isolated, and she was struggling academically. Although

A Family Entering the Publicly Funded System of Care


visiting with her mother regularly, Jennifer had been refusing to visit with her biological father who had recently been located by her protective services worker.

Robert (Bobbie) was a 13-year-old, Caucasian boy of Italian and Hispanic heritage. At the time of his admission, Bobbie was living in East Somewhere, Connecticut, with his foster mother and an 11-year-old foster sister, and he was doing very well aca- demically and socially as an eighth-grade student assigned to a mainstream classroom at Main Street Middle School. In addition to the substantiated accusations of serious neglect, there were questions about whether Bobbie had also been physically abused by a man who brie y lived with his mother. Because of his age, Bobbie also had a juvenile court case pending for failure to attend school regularly. Presenting problems included anxiety about separation from his mother and younger sister, guilt about his failure to attend school regularly, and di culty sleeping. Although visiting with his mother regularly, he was upset with his mother because she could not tell him who his biological father was.

eir mother, Donna, was a 31-year-old, single Caucasian woman of Italian heritage who has a high school diploma but no sig- ni cant work history. Shortly before her children were admitted to the clinic, she had referred herself to the adult service at the same community mental health clinic. Upon admission, she was homeless and living in West Somewhere, Connecticut, with extended fam- ily. Her psychosocial history was notable for a history of childhood trauma, residential placement as an adolescent, early pregnancy in the context of an unstable romantic relationship, failure to adequately support herself nancially, and di culty maintaining stable housing for her family. In the context of the child welfare proceedings, she presented with depressive symptoms and signs of serious personality disturbance characterized by avoidant, dependent, and compulsive traits. Although there were initially questions about limited intelligence, she demonstrated low average to average cognitive ability on standardized assessments.

A Preschool Child Entering the Publicly Funded System of Care

Gabriel was a 4-year-old boy of Hispanic heritage who was referred to the child and adolescent service at a small community men- tal health clinic by the preschool special education team within the Safe Haven Public School System. e referral represented the second e ort school sta had made to help his father secure a comprehensive psychiatric evaluation. At the time of his referral, Gabriel was living with his biological father and 2-year-old biological sister whose cognitive, emotional, and social development appeared to be appropriate for a child her age. He was enrolled in an inclusion program for preschool children with special needs. His father was a 24-year-old Hispanic man of Puerto Rican heritage whose primary language is Spanish. He was unemployed and stressed by the demands of caring for two children with limited vocational skills and minimal social support. Gabriel’s mother was a 23-year-old woman of Colombian heritage whose primary language was also Spanish. She reportedly le the family to return to Colombia to resume a romantic relationship with a man she knew as a child. During an initial meeting, Gabriel’s father com- plained about being very depressed and anxious because the family faced eviction from their apartment for failure to pay rent.

When seen for an initial assessment, Gabriel presented with signs of intellectual disability, hyperactivity, limited attentional capacity, poor impulse control, and pica. School sta were concerned that, when not closely supervised, Gabriel was eating ined- ible objects in ways that were jeopardizing his health. ey were also concerned about what appeared to be reactive aggression directed at peers in school that le them at risk for serious injury. He also presented with signs of attachment di culty character- ized by indiscriminate pursuit of caregiving from strange adults. His pediatric records documented a history of lead poisoning, inadequate well-child care, and an absence of repeated screening for lead poisoning in the context of his pica. ere was also a note that Gabriel had been referred for a pediatric neurological consultation, but the family had not kept two appointments arranged by his pediatrician. His school records documented excessive absenteeism during his rst 2 years of school that the educators thought had compromised his capacity to bene t from his program of special education. As the treatment team completed his admission evaluation, there was agreement that the clinic had an obligation to make a mandated report to child protective services because of concern about educational and medical neglect.

A School-Age Child Entering the Publicly Funded System of Care

Melanie was a 9-year-old biracial girl of European and African American heritage whose mother referred her to the child and ado- lescent service at a small community mental health clinic. She had been encouraged to do so by school sta and her protective ser- vices worker. At the time of her referral, Melanie was living in West Somewhere, Connecticut, with her biological mother, maternal grandmother, and an older sister. She was registered as a second-grade student at Main Street Elementary School, but she was not


attending school regularly. Child protective services was involved with the family because, during kindergarten and rst grade, Melanie had missed more than 50% of the school year. Because there was no evidence that Melanie had any medical problem that would warrant her missing so much school, the school social worker had made a mandated report of educational neglect to child protective services during the previous school year.

Upon admission, school sta reported that her mother frequently kept Melanie home from school, reporting she was sick. When she did not attend, her mother would consistently call the school nurse to report that Melanie was ill with some minor illness or injury. Occasionally, she would also provide a note indicating that Melanie had been seen by her pediatrician, but the notes never documented any clear signs of illness at the time of the visit. Because she had missed so much school, Melanie had been retained twice and was two grades behind her age cohort. A special education evaluation completed by school sta failed to docu- ment any emotional or learning problems. When in school, Melanie was described as a pleasant, cooperative child who was doing her school work as best she could and getting along well with her teacher and her peers.

When rst seen at the clinic, Melanie was still not attending school regularly, she was at risk to be retained again, and there was a pending legal petition to remove her from her mother’s care. Melanie presented as a quiet, compliant child who did not demonstrate any signs or symptoms of serious emotional-behavioral di culty. She indicated that she enjoyed being in school and did not identify any problems at school. She also reported that she sometimes did not feel sick when her mother kept her home from school, but she also indicated that she knew she had to do what her mother told her to do. Her mother presented as a very anxious, cooperative woman who reported she was supporting her family with disability bene ts and nancial assistance from her mother. She con rmed a long list of medical problems, acknowledged a serious sexual assault as an adolescent, and reported that her father had died unexpectedly approximately 5 years ago. She seemed to be hypervigilant about Melanie’s health and o ered a long list of childhood illnesses and injuries that she believed warranted keeping Melanie out of school. Although she faced losing custody of Melanie in several months, she insisted that the judge would understand her need to keep her child home from school when she was sick.

An Adolescent Entering the Publicly Funded System of Care

Khalid was a 15-year-old boy from Morocco who was referred to the child and adolescent service of a small community mental health clinic by his older brother who was also his legal guardian. His was of Muslim faith, and Arabic was his rst language. Upon referral, he was living with his 28-year-old brother in an apartment in West Somewhere, Connecticut, where he attended Safe Haven High School as a tenth-grade student. He was enrolled in mainstream classes with English as a Second Language (ESL) supports. Approximately 1 year prior to his admission, Khalid, who was the youngest of six children, had immigrated precipitously to the United States to live with his oldest brother a er he had witnessed the death of his parents in a motor vehicle accident. His brother’s work visa allowed them to live in the country legally, but Khalid was not eligible for Medicaid bene ts, and his family could not a ord to pay for private insurance.

Presenting problems included complaints of sadness, di culty sleeping, and myriad somatic complaints involving headaches, dizziness, joint pain, pressure in his chest, and double vision. For more than a year, Khalid had attempted to cope with his somatic complaints by praying, but when that did not prove helpful, he asked that his brother bring him to a doctor for a medical evalu- ation. Because he had no medical insurance, Khalid did not have a primary care physician and eventually went to the local emer- gency room for a physical examination and laboratory studies during an episode of dizziness. When his medical evaluation proved negative, the physician in the emergency room suggested that his complaints were psychosomatic in nature and referred him to the clinic for a psychiatric evaluation.

Although Khalid and his brother reported that psychiatric treatment is frowned upon in their culture, they agreed to seek services because Khalid was so distressed. His psychosocial history suggested that the sudden death of his parents had triggered a cascade of other interpersonal losses for Khalid as he le his home in Morocco with a simultaneous increase in psychosocial stress associated with his need to live with his brother, attend school, and make new friends in a country where he did not know the culture or the language. Anti-Arab sentiment within his new high school and his need to immediately learn English added to the stress. His family history was positive for di culty with anxiety and depression in several rst-degree relatives, and a standardized trauma screen suggested that he was experiencing symptoms of traumatic grief related to the unexpected death of his parents.



Despite more than 100 years of ongoing development, the publicly funded system of care for children and adolescents has always been confronted with a number of challenges. Some of these challenges, like access to services and engage- ment in treatment, have been long-standing and the subject of empirical investigation. Others, like concern about the use of psychiatric medication, are relatively new and shaped by independent review of the system. Still others, like the validity of psychiatric diagnoses, concern about the empiri- cal basis for practice, and the need for empirically validated treatments, are relatively new and shaped by concerns evolv- ing from within the behavioral health professions. To illus- trate some of these challenges, seven issues currently facing the system are brie y described here.


Despite the prevalence of developmental psychopathol- ogy, most minors with a documented need for psychiatric treatment do not, as noted earlier, receive treatment.37,44 Although overrepresented in the publicly funded sys- tem of care, children and adolescents from low-income families have disproportionately higher rates of unmet need.47,48 Likewise, African American, Hispanic, and Native American children and adolescents living in poverty have even higher rates of unmet need.47,48 Demographic group- ings of children and adolescents with speci c patterns of emotional-behavioral di culty also tend to have more unmet need. For example, girls with externalizing di – culty and boys with internalizing di culty are less likely to receive psychiatric services.49

Kimberly Hoagwood and her colleagues50 have de ned three clusters of potential in uences that may limit access to services: (1) structural characteristics of the system of care, (2) perception of the psychiatric di culty, and (3) per- ception of the services. Research indicates that in uences easily sorted to each cluster do, in fact, in uence access to behavioral health services. Structural characteristics of the service delivery system known to in uence access include a lack of providers, wait-lists, lack of insurance, inadequate insurance, transportation problems, inconvenient location, inconvenient hours, and lack of culturally and linguistically competent clinicians. Perceptions of the psychiatric di – culty known to in uence access include failure to identify serious emotional-behavioral di culty, denial of problem severity, denial of the need for professional services, and

belief that the problem will resolve without treatment. Perceptions of services known to in uence access include lack of trust in behavioral health professionals, negative experiences with behavioral health professionals, child or adolescent reluctance to seek services, social stigma, and parental concern about mandated reporting of potential child abuse and neglect. Limited research done with this conceptual model suggests that, despite a historical focus on structural characteristics of the service delivery system, access to services will only improve with concurrent atten- tion to perceptions of the psychiatric di culty and percep- tions of psychiatric services.50


Although problems with access to services persist for children and adolescents, engagement in treatment is a persistent problem when caregivers do seek services. Consequently, there are high rates of failure to keep an ini- tial appointment, failure to attend treatment sessions, early withdrawal from treatment, and administrative discharge for failure to attend regularly. Although there has been extensive discussion about the potential reasons for poor attendance in the face of high need and limited access, sys- tematicreviewoftheliterature51suggeststhatlocatinghelp elsewhere, competing demands at the time of the sched- uled appointment, length of wait time for the appoint- ment, dissatisfaction with the initial contact, improvement in the presenting problem, and child or adolescent refusal may contribute to failure to keep an initial appointment. Unfortunately, the results of research are not consistent, and no single in uence emerges as particularly robust across investigations.51

Similarly, Alan Kazdin and his colleagues52 argued that no single characteristic or condition appears to su ciently explain failure to attend treatment once enrolled. Research on early withdrawal suggests that family crisis, con ict with a signi cant other about treatment, problems with other children, con ict with other appointments, situational stressors associated with poverty, quality of the relationship with the clinician, perceived relevance of the treatment, and rate of clinical improvement may be some of the contribut- ing factors.52 More recently, Bruce Chorpita53,54 has argued that conceptual models of engagement need to involve more than just documentation of simple attendance, and Chorpita and his colleagues53,54 have begun to more clearly document how di erent approaches to engagement a ect three dimensions of engagement: (1) attendance at treat- ment, (2) readiness for treatment, and (3) adherence to treatment.



Comprehensive psychiatric evaluation poses many concep- tual and practical challenges for behavioral health clinicians working with children and adolescents. Conceptually, for many years, there has been tension between advocates of a categorical medical diagnosis grounded in the Diagnostic and Statistical Manual of Mental Disorders (DSM)45 or International Classi cation of Diseases (ICD)55 and advo- cates of a developmental diagnosis grounded in the prin- ciples of developmental psychopathology.56 Within the psychiatric community, there has also been controversy about the reliability and validity of psychiatric diagnoses used with children and adolescents. More recently, there has, for example, been controversy about the incorrect, incon- sistent, and excessive use of diagnoses like attention de cit hyperactivity disorder, bipolar mood disorder, and post- traumatic stress disorder in children and adolescents.57–59 With the introduction of the latest revision (DSM 5)45 in 2013, there has been concern about (1) the reliability of speci c child and adolescent diagnoses,60 (2) the reorgani- zation of autistic spectrum diagnoses,61 (3) the inclusion of disruptive mood regulation disorder,62 and (4) the exclu- sion of developmental trauma disorder.46


Medication can be e ective in the treatment of psychiatric disorders of childhood and adolescence. However, there is consensus that treatment with psychiatric medication should only be initiated a er a comprehensive psychiatric evaluation and as one component of a comprehensive treat- ment plan.63 Over the past 10 years, there has been concern about the recent and very dramatic increase in the num- ber of children and adolescents receiving speci c classes of psychiatric medications.64–66 Concern about the use of psychiatric medications with children and adolescents has been complicated by the fact that only a few large clinical trials document the safety and e cacy of psychiatric medi- cations when used in the treatment of children or adoles- cents. Moreover, most psychiatric medications approved by the US Food and Drug Administration (FDA) for use with children and adolescents have been approved following safety and e cacy testing done over relatively brief periods of time with relatively small samples. Unfortunately, rela- tively little is presently known about the long-term use of these medications with children and adolescents.

Although the Pediatric Research Equity Act (PREA) and the Best Pharmaceuticals for Children Act (BPCA) have promoted safety and e cacy research on drugs when used with children and adolescents,67 pediatric drug trials

involving psychiatric conditions have been limited,68 and much of the psychiatric medication prescribed to chil- dren and adolescents, particularly second-generation antipsychotic medication, is being prescribed for the treatment of pediatric conditions without approval of the FDA.65,66,69 Moreover, it is important to note that inde- pendent reviews of the existing research suggest that the evidence supporting federal approval of speci c drugs for use in the treatment of speci c conditions can vary signi – cantly.70 Consequently, the American Academy of Child and Adolescent Psychiatry has urged prescribers to con- sider the quality of the safety and e cacy data along with the status of federal approval when choosing psychiatric medications for children and adolescents. Examples of psychiatric medications with demonstrated e cacy and federal approval for use in the treatment of children and adolescents with speci c conditions are listed in Table 9.2.

For reasons that are not clear, children and adolescents with Medicaid receiving psychiatric services in the public sector are more likely to receive psychiatric medication than are children and adolescents with commercial insurance receiving services in the private sector.71 For children and adolescents in the publicly funded system of care, there has also been concern about (1) the use of psychiatric medica- tions at an increasingly early age,72 (2) use of more than one psychiatric medication simultaneously,73 and (3) use of psy- chiatric medications without psychosocial intervention.74 Similarly, there has been concern about children and ado- lescents involved with the child welfare system being more likely to receive psychiatric medication75,76 and relatively consistent ethnic di erences in the likelihood that children and adolescents will receive psychiatric medication. 69,72,77,78 For reasons not entirely clear, children and adolescents of African American and Hispanic heritage are less likely than children of European heritage to receive psychiatric medi- cation in the publicly funded system of care.69,72,77,78


Building on concepts concerning the empirical basis for pharmacologic intervention, there is ongoing interest in other dimensions of evidence-based practice within the publicly funded system of care for children and adoles- cents.79,80 roughout the health care system, evidence- based practice is de ned as the integration of the best available research with clinical expertise a er consider- ation of the characteristics of the client, cultural factors, and client preference.81 e goals associated with imple- mentation of evidence-based practice include improv- ing accountability, quality of care, and cost-e ectiveness by enhancing clinical assessment, case formulation, the




Attention de cit hyperactivity disorder



Dexmethylphenidate Lisdexamfetamine Amphetamine Atomoxetine guanfacine Fluoxetine Escitalopram Amitriptyline Sertraline Fluvoxamine Clomipramine Aripiprazole Quetiapine

Lithium Risperidone Paliperidone Chlorpromazine Haloperidol Aripiprazole Imipramine


Ritalin® Concerta®

Daytrana® Focalin® Vyvanse® Adderall® Strattera® IntunivTM Prozac® Lexapro® Elavil® Zolo ® Luvox® Anafranil® Abilify® Seroquel® Eskalith® Risperdal® Invega® orazine® Haldol® Abilify® Tofranil®


6 years 6 years

6 years
6 years
6 years
3 years
6 years
6 years
8 years 12 years 12 years 6 years
8 years 10 years 10 years 10 years 12 years 13 years 12 years 6 months 3 years 10 years 6 years

Depressive disorders

Obsessive-compulsive disorder

Bipolar disorder


Tourette’s disorder Enuresis

therapeutic relationship, and clinical intervention.82 e main elements of evidence-based practice involve (1) the use of evidence-based approaches to engagement, (2) the selection of clinical interventions that have empiri- cal support for use with the target population, (3) formal assessment of targeted outcomes, and (4) ongoing moni- toring of response to treatment with sensitivity to the developmental status of the client, cultural beliefs of the family, and treatment preferences of the family.82

It is important to note that evidence-based practice is a widely encompassing concept. Narrower concepts involv- ing empirically validated approaches to assessment and

treatment are also emphasized within the publicly funded system of care for children and adolescents. Empirically validated assessments and treatments are evaluative and treatment procedures that have undergone standardiza- tion, empirical testing, and rigorous review to document their validity when used with a particular population pre- senting with a particular problem.83 e two dimensions on which assessments are judged are reliability and valid- ity. ree dimensions on which clinical interventions are judged are (1) clinical utility or the extent to which the treatment is applicable, feasible, and useful; (2) clinical e cacy or the extent to which the treatment works in a


research setting ; and (3) clinical e ectiveness or the extent to which the treatment works when delivered by clini- cians in a system of care. e Society for Clinical Child and Adolescent Psycholog y84 and SAMHSA85 maintain resource lists of empirically validated psychosocial treat- ments for use with children and adolescents experiencing speci c forms of emotional-behavioral di culty. Examples of empirically validated psychosocial treatments for use in the treatment of speci c conditions common among children and adolescents are listed in Table 9.3. Although principles of evidence-based practice are more widely accepted, there is ongoing controversy about how to best integrate empirically validated assessments and treatments into the publicly funded system of care for children and adolescents.86


As noted earlier, children and adolescents entering the publicly funded system of care typically present with involvement in other publicly funded service delivery

systems. Moreover, the concept of a system of care also values interagency collaboration in the assessment and treatment of serious emotional-behavioral di culty and seeks ways to actively promote collaboration across ser- vice delivery systems.22,24 Consequently, behavioral health professionals working in the publicly funded system of care for children and adolescents must communicate and collaborate with professionals working in school readi- ness programs, pediatric clinics, educational settings, juvenile justice programs, child welfare systems, and other community-based programs. When parents also need behavioral health services, there must also be communi- cation and collaboration across the pediatric and adult systems of care. Despite the long-standing emphasis on interagency collaboration,22,24 repeated calls have been made for better collaboration across service delivery sys- tems that intersect to serve children and adolescents with serious emotional-behavioral di culty.30,31 Although policy initiatives, pilot projects, and systemic reforms have been pursued, communication, collaboration, and integration across service delivery systems remain some of



Individual psychotherapy

Parent intervention

Family therapy

Home-based intervention Multisystemic intervention


Traumatic stress Depression

Social phobia Externalizing di culty

Externalizing di culty Substance abuse
Mood disorders
Early autism Externalizing di culty Externalizing di culty Conduct problems Substance abuse


Trauma-Focused Cognitive Behavioral erapy Interpersonal Psychotherapy for Depressed Adolescents

TADS Cognitive-Behavioral erapy Coping Cat

Parent Management Training
Parent-Child Interactional erapy
Triple P Positive Parenting Program
Brief Strategic Family erapy
Functional Family erapy
Multi-Family Psychoeducational Psychotherapy Lovaas Approach to Applied Behavior Analysis Multidimensional Treatment Foster Care Incredible Years

Multisystemic erapy Multidimensional Family erapy


Note. is list of examples was extracted from databases maintained by the Society for Clinical Child and Adolescent Psychology84 and the Substance Abuse and Mental Health Services Administration.85


the more daunting challenges facing the publicly funded system of care for children and adolescents.


As the health care system has become increasingly special- ized, gaps between pediatric and adult systems have grown to the extent that Healthy People 202087 includes a national goal that calls for adolescents with chronic conditions to receive the services they need to make a successful transi- tion from the pediatric to the adult system of care. For ado- lescents with serious emotional-behavioral di culty, this transition from the pediatric to the adult system of care is as complicated as it is for adolescents with other chronic, recurring health problems. As the concept of a system of care has evolved, the sensitive transition of adolescents with serious psychiatric di culty from the pediatric to the adult system of care has become one of the important principles of e ective service delivery.88

Given the focus of this textbook, it is important to highlight four trends that have converged in the public sec- tor to make young adults with psychiatric di culty a spe- cial population within the publicly funded systems of care. First, social and economic in uences have changed the transition from adolescence to early adulthood. Second, epidemiologic research has more clearly documented the risk for psychiatric di culty during this transition from adolescence to early adulthood. ird, developmental research has better documented patterns of continuity and discontinuity in psychopathology that begins during childhood, frequently escalates during adolescence, and then continues into early adulthood. Fourth, service deliv- ery systems have, as noted, become more sensitive to the needs of transitioning youth.


Noting that social, economic, and technological changes have rede ned the transition from adolescence to early adulthood, Je rey Arnett89 has argued for the concep- tualization of a new period of biopsychosocial devel- opment that occurs between 18 and 25–30 years of age when, despite being granted legal status as an adult, young people do not think of themselves as either adolescents or adults. Over approximately 40 years, widespread avail- ability of e ective contraception, changing values about premarital sexual relations, demands for postsecondary

education, broad acceptance of cohabitation, the high cost of living, and other social forces have contributed to a dramatic delay in the age at which young people meet the traditional developmental milestones of early adult- hood,90,91 thus creating a period during which young people report feeling as if—despite having reached the age of majority—they are still preparing for adulthood.89 Given these changes, Arnett has argued that this time is substantial enough and distinct enough to now be con- sidered a speci c stage of development in technologically advanced cultures. Rejecting other labels in favor of a new description of a new phenomenon, Arnett89 began calling this phase of life emerging adulthood to capture the idea that young people use this time to develop the social and psychological resources they need to successfully negoti- ate the demands of adulthood in an increasingly complex, technologically oriented culture. Although there has been debate about elements of his position,92–94 Arnett,89,95,96 more than anyone else, has focused the attention of devel- opmental researchers on this phase of life, and they are identifying important markers of biopsychosocial devel- opment in the areas of neurological development, a ec- tive regulation, cognitive capacity, identity development, psychosexual development, vocational-educational plan- ning, and family functioning.97–101


Across the life span, epidemiologic research clearly indicates that risk for the onset of chronic recurring anxiety, mood, and psychotic disorders peaks during emerging adult- hood.102 When substance use disorders are included, the highest rate of behavioral health disorders occurs among young adults aged 18–25 years.103 Much of the risk within this age group is accounted for by much higher rates of substance use disorders and higher rates of concurrent sub- stance use and psychiatric disorders. Risk for major depres- sion and suicidal ideation are most clearly highest during this developmental period. Epidemiologic data also sug- gest that substance use, high-risk sexual behavior, sexually transmitted infections, unplanned pregnancy, unemploy- ment, homelessness, and death due to accident, homicide, and suicide rise, peak, and then begin to decline during this developmental period.104 Within this age group, rates of behavioral health disorders appear to be highest among young people of Native American heritage followed by young people of European, African American, Hispanic, and Asian heritage. Within this age group, approximately 4% of the general population has a serious psychiatric dis- order, and serious psychiatric disorders are more common


among young women than young men. Consistent with other age groups, substance use disorders are more common among young men. Despite the higher prevalence of behav- ioral health problems during this phase of life, young adults are less likely than other adults to seek treatment.


Developmental perspectives on psychopathology have provided a more comprehensive understanding of psychi- atric di culty during emerging adulthood. Longitudinal research done with large samples of children followed through childhood and adolescence into early adult- hood suggests that, although serious emotional-behav- ioral di culty evident during childhood and adolescence attenuates for many young adults, there can also be a consolidation of psychiatric di culty, personality distur- bance, and social problems during this phase of life that represents risk for persistent di culty as an adult.102 As noted earlier, risk for the onset of chronic recurring anxi- ety, mood, and psychotic disorders peaks during this time of life. Regardless of the course of the psychopathology, developmental research suggests that young adults with a history of psychiatric di culty are more likely to expe- rience di culty negotiating developmental challenges associated with the transition to adulthood.105 ey are, for example, less likely to complete high school, less likely to successfully pursue postsecondary education, and less likely to secure stable employment. ey are also more likely to be estranged from an unstable, con ictual family of origin without access to the emotional, instrumental, and nancial support from family that continues to be important during the transition to adulthood.106 Relative to their peers, young adults with psychiatric di culty are also more likely to experience di culty in sexual part- nerships, more likely to marry early, and more likely to become parents early without the social and economic resources necessary to adequately support children. Box 9.3 contains a ctional clinical vignette illustrating the typical presentation of a young adult making the transi- tion from the pediatric to the adult system of care.


In 2005, the MacArthur Foundation Research Network on Transitions summarized its ndings on transitions from child and adolescent to adult systems of care in a book aptly titled, On Your Own Without a Net. In that document, D. Wayne Osgood and his colleagues105 identi ed seven

overlapping groups of transitioning youth at risk to fall through gaps in the human service system during the transi- tion to adulthood: (1) youth involved with the child mental health system, (2) youth in foster care, (3) youth receiving special education services, (4) homeless youth, (5) youth with special medical needs, and (6) youth involved with the juvenile justice system. During this transition to adult- hood, vulnerable youth with complex service needs are likely to nd that services they need are no longer available, services they need are less available, eligibility for services is de ned di erently, and the scope of services is dramatically di erent.105

Because young adults leaving the publicly funded sys- tem of care for children and adolescents are more likely to have been receiving services in several service delivery sys- tems, disruptions in social support during this transition to early adulthood are likely to have a signi cant impact on the stability of their social situation. As noted by Osgood and his associates,105 di culty managing systemic transitions o en increases the risk for educational failure, unemploy- ment, early parenthood, homelessness, criminal activity, victimization, and poverty. Di culty negotiating systemic issues may also contribute to an escalation of psychiatric di culty. Moreover, even when young adults make the sys- temic connections they need, they o en nd themselves in systems of care oriented to the needs of middle-aged adults working with clinical sta who, because of shortcomings in patterns of professional training, do not fully understand their development as a young adult.105

Despite growing interest in the needs of transitioning youth, there are few conceptual models of service delivery for young adults experiencing serious psychiatric di culty. Policy-makers, researchers, and clinicians have, however, begun e orts to better address gaps in the publicly funded system of care to better address the special needs of tran- sitioning youth with psychiatric di culty. For example, the US Government Accountability O ce107 undertook a study of transitioning youth with psychiatric di culty in 2008. A year later, SAMHSA funded the Emerging Adults Initiative,108,109 which provided funding for seven states to create developmentally informed systems of care designed to better address the needs of transitioning youth. As the rst round of grants came to an end, SAMHSA issued another call for proposals to continue the program as part of the Now Is the Time Plan110 to reduce gun vio- lence. As they begin to evolve, the primary goal of special- ized services for transitioning youth is to stabilize them, as much as possible, in a community-based system of care for adults in an e ort to reduce the personal and social costs of the psychiatric di culty by promoting developmental


Box 9.3

A Young Adult Entering the Publicly Funded System of Care

Shamika was an 18-year-old, single African American woman who was referred for admission to a special young adult program at a large, urban community mental health center. At the time of her referral, she was living in a group home for teenage girls in the custody of child protective services, and she had just completed her high school education in a special education program for students with serious emotional disturbance.

Shamika had an extensive history of emotional-behavioral di culty associated with a long history of childhood trauma. Her mother was reportedly a loving parent with a history of recurrent major depressive episodes that frequently required she be hospi- talized for psychiatric treatment. Her father was reportedly an angry, alcoholic man who provided nancial support for the family through his job as a long-haul truck driver. He was reported to be emotionally and physically abusive with his wife. When 11 years old, Shamika had been removed from the care of both her biological parents a er her older sister reported that she, Shamika, and a younger sister were being physically and sexually abused by their father. Although there were early signs of psychosexual di – culty, Shamika had always insisted that, although she knew her father was mistreating her older sister, he had never mistreated her. A er removal from her parents’ care, Shamika had been placed with a friend of her mother, several other foster placements, and a residential school. As she moved through this series of placements, she acknowledged that she had been sexually abused by a foster mother’s boyfriend and a residential counselor.

Presenting problems at the time of her admission to the young adult service included hypervigilance, referential thinking, emo- tional lability, verbally and physically aggressive behavior with peers, and sexually provocative behavior with male peers and older men. roughout her medical records, there was documentation that Shamika also su ered from dissociative episodes during which she would behave in sexually provocative ways with limited memory of what had happened. During some of these episodes, she would engage in high-risk sexual behavior with men she did not know. Although interested in monogamous romantic relation- ships with young men, these encounters had been marked by reciprocal verbal, physical, and sexual aggression. Her relationships with young women were, by her report, generally poor. Upon admission, Shamika was referred for residential placement in a tran- sitional living program, individual psychotherapy, vocational-educational services, occupational therapy, social and recreational activity, and psychiatric consultation. By her report, she was motivated to be responsible for her behavior as an adult, be more independent, leave the child welfare system, have a better relationship with her boyfriend, get a job, attend community college, see her mother more o en, and move into her own apartment.

competence. Given current understanding of the target population, evolving programs for transitioning youth need to also develop clear mechanisms to reduce risk for substance abuse, high-risk sexual behavior, vocational-edu- cational failure, homelessness, and premature death by an accident, suicide, or homicide.

With acknowledgment of the early e orts, it is impor- tant to note that there are relatively few specialized pro- grams for transitioning youth that have been proved clinically and cost-e ective. Although the literature on clinical and systemic outcomes is limited, ndings from several federal initiatives suggest that transitioning youth enrolled in specialized programs can make substantial gains.108,109 Speci cally, the SAMHSA reported that 28% of transitioning youth in a special program con rmed sig- ni cant improvement in emotional-behavioral di culty during the rst 6 months of enrollment, and 38% reported signi cant improvement in emotional-behavioral di culty within the rst 12 months of enrollment. Rates of home- lessness also dropped by 36% over the rst 6 months of

enrollment for those participants older than 18 years of age, and participants of all ages reported having more con- dence in their ability to independently perform important life tasks. Although there is obviously a great deal of con- ceptual and empirical work to be done as the development of comprehensive programs designed to reduce the psychi- atric di culty and promote normative development during this transition to early adulthood continues, policy-makers, administrators, and clinicians on both sides of the pediat- ric-to-adult transition in the publicly funded system of care need to consider how to better address the developmental needs of young adults with psychiatric di culty.


As policy-makers pay close attention to the education, credentialing, and orientation of the next generation of


behavioral health clinicians to work in public psychiatry, there have been consistent calls for more professionals and paraprofessionals competent to work with children, ado- lescents, and young adults in the publicly funded system of care.111 Nationally, there are particular needs for child and adolescent psychiatrists and substance abuse counselors prepared to work with adolescents and young adults.112,113 Although there are clear mechanisms for professional train- ing in clinical work with children and adolescents, there are relatively few structured opportunities for graduate or postgraduate training in clinical work with transitioning youth. Following the general structure of public psychiatry, professional training programs typically identify themselves as focusing on the mental health needs of either children and adolescents or adults. With increased attention to the needs of transitioning youth with serious psychiatric di – culty, there are, however, new programs designed to intro- duce clinicians to clinical work with transitioning youth entering the publicly funded system of care for adults. e rest of this section focuses on professional preparation in the traditional behavioral health disciplines of psychiatry, psychology, nursing, and social work. It is, however, impor- tant to note that marriage and family counselors, licensed professional counselors, occupational therapists, other credentialed professionals, and an array of paraprofession- als also work within the publicly funded system of care for children, adolescents, and young adults.


Career paths to child and adolescent psychiatry typically involve completion of medical school, a general psychia- try residency, a child and adolescent psychiatry fellowship, a license to practice medicine, and board certi cation in child and adolescent psychiatry. e American Council on Graduate Medical Education accredits general psychia- try residency programs and child and adolescent psychia- try fellowships. At this time, there are approximately 130 accredited child and adolescent psychiatry fellowships.114 Traditionally, this involves 2 years of specialty training a er 3 or 4 years of a general psychiatry residency. Some programs also o er an integrated program in which both adult and child and adolescent training are completed in 5 years, and there are combined programs in pediatrics and child and adolescent psychiatry. Psychiatric residency training programs are, however, most frequently based on tradi- tional ideas about psychosocial development that hold that adolescence ends and adulthood begins at 18 years of age. Consequently, neither adult nor child and adolescent pro- grams typically include focused training in the delivery of

developmentally informed services to young adults. With the ongoing development of clinical programming to bet- ter meet the needs of transitioning youth with serious psy- chiatric di culty, special rotations on young adult services are beginning to be o ered on a limited basis to child and adolescent and adult psychiatry residents. Following com- pletion of residency, the American Board of Psychiatry and Neurology o ers specialty certi cation in child and ado- lescent psychiatry,115 and the American Academy of Child and Adolescent Psychiatry has a program to recognize dis- tinguished fellows for their contribution to the specialty.116


Career paths to clinical child and adolescent psychology typically involve a doctoral degree in professional psychol- ogy, a doctoral internship and postdoctoral fellowship in clinical child and adolescent psychology, and licensure as a professional psychologist. Most o en, students earn a doctoral degree in clinical psychology in a program that allows for a focus on clinical child and adolescent psychol- ogy. ere are also some combined programs in clinical and school psychology or clinical and developmental psychol- ogy. Students usually earn either a doctor of philosophy or doctor of psychology degree. e American Psychological Association (APA) accredits both doctoral training pro- grams and doctoral internships.117,118 e Society for Clinical Child and Adolescent Psychology maintains a list of APA-accredited doctoral internships and postdoctoral fellowships in clinical child and adolescent psychology,119 and the American Board of Clinical Child and Adolescent Psychology o ers board certi cation for advanced practice with children and adolescents.120 Although not system- atically addressed in doctoral training programs in clinical psychology, doctoral internships and postdoctoral fellow- ships focusing on clinical work with young adults have begun to emerge,121 and the Society for Clinical Child and Adolescent Psychology recently began a special interest group for clinicians, researchers, and educators interested in clinical work with young adults.122


Career paths to psychiatric nursing typically involve a bachelor of science degree in nursing, a master of science or doctorate of nursing practice degree in psychiatric- mental health nursing, national certi cation, and licensure as an advance practice registered nurse or nurse practi- tioner.123 Requirements for licensure vary from state to


state. Although the American Association of Colleges of Nursing recommends the entry-level credential for advanced practice nursing be the doctorate of nursing practice degree by 2015,124 most states have not changed the minimum requirements for licensure. e Commission on Collegiate Nursing Education accredits graduate train- ing programs,125 and the American Nurses Association provides board certi cation for psychiatric-mental health nurse practitioners with a life span focus and child and adolescent psychiatric-mental health clinical nurse special- ists through the American Nurses Credentialing Center.126 Although board certi cation as a psychiatric-mental health nurse practitioner allows for practice across the life span, psychiatric nursing does not yet have any professional ini- tiatives devoted speci cally to meeting the needs of young adults.


Career paths to psychiatric social work with children and adolescents typically involve a master of social work degree involving 2 years of graduate study with eld placements in a system of care. Under some circumstances, a bachelor and master of social work degree can be completed in 5 years. Programs of study are accredited by the Council on Social Work Education,127 and some programs o er a specialty track or specialty concentration for students interested in working with children, adolescents, and their families in a variety of settings. Students interested in clinical work with children and adolescents can also usually choose eld placements in settings that o er psychiatric services to chil- dren and adolescents. Following graduation, most states require a period of supervised practice before licensure. Again, professionals interested in establishing credentials as a child and adolescent clinician can complete that period of supervised practice in a setting that o ers psychiatric services to children and adolescents. Some clinical settings o er a postgraduate fellowship in psychiatric social work with children and adolescents. e National Association of Social Workers has a specialty section on practice with chil- dren, adolescents, and young adults,128 and the organization o ers an advanced certi cation in practice with children and adolescents.129


Over more than 100 years, the publicly funded system of care for children and adolescents with serious emotional- behavioral di culty has evolved from historical roots that

di er rather dramatically from those of the publicly funded system of care for adults. Despite the historical di erences, the publicly funded systems of care for children, adolescents, and adults share some guiding principles. Within the pub- licly funded system of care for children and adolescents, the concept of a system of care has, more than anything else, in uenced the development of the service delivery system. Despite e orts to develop a coordinated system of care for children and adolescents, problems with access and engage- ment continue, and most children and adolescents expe- riencing psychiatric di culty do not receive appropriate services.

When caregivers do seek services, children and adoles- cents entering the publicly funded system of care typically present with both acute and chronic di culty characterized by internalizing pathology, externalizing pathology, and substance abuse. Psychopathology is typically complicated by social problems associated with poverty, and concurrent involvement with other service delivery systems is common. Although the system of care for children and adolescents faces a number of challenges emanating from within and outside the system, there are special challenges associated with workforce development and the need to better bridge systems of care for adolescents whose psychiatric di culty persists during the transition to early adulthood. To better serve adults seeking assistance within the publicly funded system of care, behavioral health professionals need to have a good basic understanding of developmental perspectives on psychopathology and the publicly funded system of care for children, adolescents, and young adults so that they are in a better position to provide empirically based assessment and intervention in a complex health care system that typi- cally separates the care of children and adolescents from the care of adults.


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Jessica M. Pollard, Cenk Tek, Scott W. Woods, omas H. McGlashan, and Vinod H. Srihari


• Psychotic disorders like schizophrenia are costly and, historically, have typically been disabling.

• Treatments earlier in the course of psychotic disorders have a greater impact on illness trajectory and long-term functioning.

• Duration of untreated psychosis (DUP) is the length of time between onset of active psychotic symptoms and connection to appropriate psychiatric care.

• Long DUP is associated with negative outcomes, including suicide, poor functioning, diminished response to antipsychotic medication, and reduced quality of life.

• Early detection (ED) aims to shorten DUP and includes outreach and education campaigns that can reduce harmful delays in accessing care a er psychosis onset.

• Early intervention (EI) includes both ED and programs that attempt to systematically deliver empirically based treatments to those presenting with a rst episode of psychosis.

• Predicting who is at ultra-high risk of developing psychotic disorders and preventing or delaying their onset has been demonstrated. Accuracy is improving with the accumulation of large datasets and biological measures.


Psychotic disorders are a source of signi cant distress, dis- ability, and cost under usual systems of care. Each year in the United States, approximately 100,000 young persons will experience the onset of a chronic psychotic disorder.1 Schizophrenia spectrum disorders rank among the top 20 sources of Years Lived with Disability (YLD) world- wide and constitute the single largest driver of health care costs among serious mental illnesses in the United States.2 Despite advances in treatment, the majority of patients with schizophrenia endure partial remission of positive symptoms with enduring negative symptoms and cognitive dysfunction. In usual systems of care, this can translate to

limited functional recovery. Persons with chronic schizo- phrenia are more likely to be single, unemployed, without health insurance, and homeless. In addition, individuals with chronic psychotic disorders die on average 20 years before their peers, with much (>80%) of this excess mor- tality attributable to cardiovascular disease.3–5 e common lack of insight into psychotic symptoms by persons with these illnesses can threaten engagement with and adherence to treatment and challenge the establishment of collabora- tive therapeutic relationships. For every person a ected by psychotic illness, there are many more around them— friends, family, and other supports—who are also impacted, and perceived caregiver burden is high among those who have a relative with schizophrenia.6


Psychotic disorders typically emerge during an already vulnerable period of life. With a peak onset between the ages of 15 to 25, psychosis can disrupt developmentally important transitions from adolescence to adulthood and derail evolving instrumental capacities. Furthermore, many potentially modi able prognostic factors emerge soon a er psychosis onset including suicidality, symptomatic relapses and rehospitalization, violence, substance misuse, social iso- lation, negative symptoms, and cognitive dysfunction.7

Despite the complicated challenge of e ectively treat- ing psychotic disorders, there are strong grounds for opti- mism. Over the past two decades, innovative e orts by research groups around the world have yielded a wealth of information relevant to the prediction, prevention, and early treatment of psychotic illnesses. is chapter provides an overview of these e orts to empower the recent entrant to public psychiatry to participate in this exciting area of research, education, clinical care, and health care policy.


A diagnosis of schizophrenia can generate undue pessimism. Poor outcome became part of the diagnostic description in Diagnostic and Statistical Manual of Mental Disorders (DSM III), although this was supported by circular reason- ing (i.e., if people diagnosed with schizophrenia recovered functioning, they must not have had the illness). However, early intervention (EI) research and other improvements in the treatment of psychosis have challenged that outlook.

In 1992, researchers and clinicians in Melbourne, Australia, established the Early Psychosis Prevention and Intervention Centre (EPPIC). Long-term out- comes for EPPIC were better than for individuals with chronic schizophrenia, including higher rates of employ- ment, symptomatic remission, and lower suicide rates.8 Researchers at EPPIC then began systematically assessing and following young people presenting with low-grade or subthreshold psychotic symptoms who were believed to be at risk for psychosis. ey developed an assessment tool, the Comprehensive Assessment of At Risk Mental States (CAARMS)9 and opened the Personal Assessment and Crisis Evaluation (PACE) clinic in 1995 to serve and study this population.

In Norway, in 1997, the Treatment and Intervention in Psychosis early detection (ED) study (TIPS) began testing a duration of untreated psychosis (DUP) reduction strat- egy that coupled rapid response teams with massive infor- mation campaigns to educate health care providers and the general public about the warning signs of psychosis and

the importance of early treatment. e resulting ED was associated with signi cant advantages in cognitive, nega- tive, and depressive symptoms compared to usual detec- tion over 5 years10 and superior functioning over 10 years.11 Concurrently, McGlashan and colleagues at Yale developed the Scale of Prodromal Symptoms (SOPS) and an accom- panying semi-structured interview to elicit and rate pre- psychotic phenomenology, the Structured Interview for Prodromal Syndromes (SIPS).12 An International Early Psychosis Association (IEPA) was formed, and numerous prediction, prevention, and rst-episode treatment and research programs began to appear around the world.

e Connecticut Mental Health Center (CMHC) has played an important role in the development of EI and prevention in psychotic disorders. e Yale pro- grams of Psychosis Risk Identi cation, Management, and Education (PRIME) and Specialized Treatment Early in Psychosis (STEP) have a history of developing cutting- edge assessment and treatment strategies for emerging psychotic disorders. PRIME was founded in 1996 and consists of an interdisciplinary team pro cient in both clinical practices and research methodology. Representing the “patchwork” funding still largely necessary in the United States for development of EI services, the work of the clinic is supported largely by research grants, mostly from the National Institute of Mental Health (NIMH), but also from the pharmaceutical industry (for clinical trials of medication treatment) and from private donors (e.g., the Staglin Music Festival). In addition to conduct- ing research, the tasks of the clinic include educating the potentialreferringcommunityaboutthesignsandsymp- tomsofpsychosisriskanddevelopinganetworkofclini- ciansandeducatorswhoreferpotentialat-riskcandidates for evaluation at the clinic.

PRIME is dedicated to the diagnosis, study, and treatment of patients who meet psychosis risk criteria (see Table 10.1). Clientele includes the patients, their fami- lies, and members of the referring network and can also include key people from the patient’s educational system. Each of the numbers comprising our published group sta- tistics represent an individual struggling with the immense daily task of growing up, of negotiating the last major phase of neurological development. Our patients illustrate, o en painfully, that this developmental trajectory can suddenly and sometimes without warning swerve sideways from its expected path. Sometimes this liability toward slippage is foreshadowed by prior expressions of vulnerability, such as early childhood de cits in social or cognitive capacity or psychotic-like perceptual experiences. However, the neuro- developmental processes that appear to lead to the majority



Attenuated Positive Symptoms Syndrome (APS):

1. Abnormal unusual thought content, suspiciousness, and/or
organization of communication that is below the threshold
of frank psychosis, AND

2. ese symptoms have begun or worsened in the past
year, AND

3. ese symptoms occur at least once per week for the last
month on average, AND

4. Psychosis can be ruled out.

Brief Intermittent Psychotic Symptoms Syndrome:

1. Frankly psychotic unusual thought content, suspiciousness, grandiosity, perceptual abnormalities, and/or organization
of communication, AND

2. ese symptoms have begun in the past 3 months, AND

3. e symptoms occur currently at least several minutes per
day at least once per month, AND

4. Psychosis can be ruled out.

genetic Risk and Functional Deterioration Risk Syndrome:

1. First-degree relative with history of any psychotic
disorder OR

2. Schizotypal personality disorder in the patient, AND

3. Substantial functional decline in the past year as measured
by gAF, AND

4. Psychosis can be ruled out.


1. Frankly psychotic unusual thought content, suspiciousness,
grandiosity, perceptual abnormalities, and/or organization
of communication, AND

2. Symptoms are disorganizing or dangerous, OR

3. Symptoms occur more than 1 hour per day more than four
times per week in the past month.

of cases of psychotic disorder (e.g., aberrations in the man- agement of synaptic pruning) do not become biologically online and active until adolescence.

To address the concern of previous psychosis risk stud- ies being underpowered, PRIME, along with similar clinics in the United States and Canada, formed a research consor- tium, the North American Prodrome Longitudinal Study (NAPLS). In its rst iteration, NAPLS produced the larg- est sample of longitudinally followed psychosis risk subjects (N = 291) worldwide and a large dataset, producing an algo- rithm with high positive predictive power for conversion to psychosis (~80%), albeit modest sensitivity (~40%).13,14 ese e orts led to a second NIMH-funded iteration with the original eight sites, known as NAPLS 2, which is antici- pated to recruit a large enough sample of subjects to address fundamental questions regarding neurobiological correlates in the development of psychosis.15

When conversion to full-blown psychosis occurred, the PRIME sta experienced considerable di culty nding providers to care for these patients, especially when family income or insurance status made them ineligible for public- sector care. e notion of creating a clinic for rst-episode

psychosis patients was raised. We expected that many indi- viduals experiencing an initial psychotic episode would require lower intensity, longer term treatment that could accommodate active work or school schedules. Several other arrangements had been previously attempted locally but failed because of the mismatch between ideal clinical care and available reimbursement structures. We concluded that nancial incentives within the local private sector were not favorable and thus focused on public-sector options. As part of this planning process, the workgroup identi ed three relevant barriers to constructing an optimal EI service in the Connecticut public sector. First, our state mental health centers are under no obligation to accept privately insured patients. Our clinical experience indicated that such individuals o en lost employment-based coverage a er a psychotic break or aged out of parental coverage and thus represented an important target group for any EI program. Many of these patients were eventually treated in the state mental health system but o en a er a long period of poor access to treatment and a er too much time had elapsed for EI to be clinically meaningful. Any EI service that excluded these patients would thus miss an important opportunity for indicated prevention. Second, Connecticut cares for adolescents and young adults via separate agencies, thereby fragmenting potential interventions aimed at the peak ages of onset of psychotic illnesses. ird, the division of pub- lic mental health care services by geographic catchment areas would limit the collection of a critical mass of early- psychosis patients around which to organize care.

e CMHC presented an excellent location to pilot an EI service. e center has a long history of support- ing clinical research programs, including PRIME. Given our interest in developing a nationally relevant model of care, we saw that CMHC o ered three distinct advan- tages. First, it is owned by the Connecticut Department of Mental Health and Addiction Services (DMHAS), which is one of 50 nationwide single state agencies (SSAs) for mental health that together constitute a de facto national mental health system. Although the degree of state funding and the role of the SSAs in mental health care vary across states, these agencies provide a link to administrative structures and personnel who are experi- enced in treating serious mental illnesses. ese resources could serve as a platform for national implementation of early intervention. Second, the SSAs bear the brunt of the nancial burden and thus have the greatest incentive to reduce disability from psychotic illnesses. ird, through Medicaid, each of the SSAs already participates in cost- sharing arrangements with the federal government that could be adapted to an EI initiative.



In 2006, the CMHC and the DMHAS agreed to support a pilot project by accepting a limited number of patients who were early in their illness course and for whom the center had no statutory obligation to provide care (i.e., individuals who were privately insured or living outside the catchment area or under age 18). is decision removed the three barriers identi ed by the workgroup, and the STEP clinic was established. Over the years, STEP has been sta ed by many talented clinical providers: aca- demic psychiatrists, psychologists, and trainees from Yale’s Department of Psychiatry and DMHAS-employed social workers, nurses, and mental health workers. All clinical personnel were drawn from the existing chronic psychosis ambulatory team at CMHC. With funding from the NIMH and a private foundation (Donaghue Foundation), STEP conducted the rst US randomized controlled trial (2007–13) to test the e ectiveness of this rst-episode service. e results demonstrated that EI and well-organized care is cost-e ective and can have signi – cant bene ts for individuals experiencing early psychosis (study details are presented later in this chapter). Despite very limited recruitment e orts, the STEP clinic received referrals at the rate of about two per week within the rst few months, with many more inquiries by phone and e- mail from area clinicians, families, and patients. Given evidence of high clinical need and the e ectiveness of the service, the leadership of DMHAS committed funding to convert STEP from a research pilot program into a regular clinical service at CMHC in 2013. is allowed for the recruitment of full-time sta for the service, including a clinical director. Additional funding from the Substance Abuse and Mental Health Services Administration (SAMHSA) allowed further expansion of vocational services. In 2014, STEP began a new National Institutes of Health (NIH)-funded initiative to test a campaign to reduce the duration of untreated psychosis in eight surrounding towns and modeled on the TIPS project described earlier. is campaign will use a variety of mass and social media outlets combined with professional out- reach to hasten access to care and enable STEP to model a population-based approach to improving outcomes for psychotic disorders.16

Public–academic collaboration has been pivotal for the development of PRIME and STEP. Speci cally, state DMHAS support enabled initial resourcing of clinical ser- vices to allow outcomes assessments and subsequent grant- funded projects. Such data will contribute to an evaluation of the cost-e ectiveness of early intervention in a “real- world” US setting. e nal outcomes, as well as the imple- mentation experience from demonstrations such as these,

can provide a reasoned basis from which the various payers in our health care system can determine the allocation of scarce health care dollars.

e work described here has contributed to a growing consensus toward implementing EI in the United States. is represents a growing alignment of psychiatry with mainstream health care, in which practical strategies to prevent morbidity have greater acceptance. Widespread adoption of EI has not been achieved, however, and much work remains to reduce stigma and pessimism regarding the outcomes of psychotic disorders in both public per- ception and within psychiatry. Some countries, such as the United Kingdom, now have nationwide ED and treat- ment programs; others have little or none. In the United States, EI has typically been in the form of research pro- grams at academic centers. However, in 2009, the NIMH announced funding for a large-scale study of rst-episode services (FES)—Recovery A er an Initial Schizophrenia Episode (RAISE)—to determine the e cacy of a pack- age of interventions designed to be readily adoptable in “real-world settings.” e NIMH has advocated that the question is “not whether early intervention works for FEP, but how specialty care programs can be imple- mented in community settings throughout the United States” (emphasis added).17 In January 2014, President Obama signed into law the Consolidated Appropriations Act, which acknowledges that most persons with serious mental illnesses experience symptoms in adolescence and young adulthood, that there are long delays in accessing evidence-based care, and that other countries have viable EI models for reducing symptoms, illness relapse, and deteriorations in functioning. is legislation was accom- panied by an approximately $25 million set-aside in the SAMHSA block grant funding program to support the development of evidence-based EI programming across the United States.



EI for psychotic illnesses can be conceptualized as includ- ing one or more of two interlocking elements. First are ED e orts that seek to minimize delay in initiating treat- ment of manifest illness. is delay has been operation- alized internationally in various measures of the DUP. e second element is the provision of “phase-speci c” interventions that are adapted to younger patients and


their families who are confronting the recent onset of a psychotic illness. Although several trials of individual pharmacologic and psychological treatments—o en adapted from studies of chronic patient samples—have been mounted, the myriad needs of patients and their caregivers necessitate services that deliver packages of such empirically supported treatments. Such comprehen- sive FES typically provide care for the rst 2–5 years a er onset of a diagnosable psychotic disorder. e work of the STEP program is best understood as serving these related aims, rst in testing a model of FES and, more recently, in launching an ED initiative.16

In chronic illnesses, “prevention” refers to interven- tions for persons who are not currently a ected by a dis- ease, and these interventions are intended to decrease future manifestation of the disease. is conception of prevention demands that cost-bene t analyses inform the application of interventions to appropriate populations so as to reduce overall morbidity and/or mortality. us, universal prevention (e.g., wearing of seat belts) is recom- mended for all, whereas selective prevention (e.g., in uenza vaccination for high-risk groups such as elderly adults) can only be justi ed for subpopulations. Finally, indicated pre- ventions (e.g., medications for control of high blood pres- sure) o en involve professional expertise and entail more risk but can be justi ed based on their ability to prevent the onset or signi cantly ameliorate the course of subse- quent disease (in this case, stroke or myocardial infarc- tion). In this view, interventions for adolescents and young adults who are discovered to be at signi cantly increased risk for a psychotic disorder might be seen as closely fol- lowing upon indicated prevention. e help-seeking sam- ples currently presenting to prodromal clinics are typically already su ering the e ects of mental disorder and have a variety of poor psychosocial outcomes even when they do not convert to psychosis.18,19 Although no e ective preven- tive approaches have yet been substantiated for psychotic illnesses, there is a strong argument for proactive e orts to o er low-risk psychosocial interventions for these high- risk patients and their families and to continue to test a variety of interventions that might survive a cost-bene t analysis to prevent morbidity. Such e orts, led by clinics such as PRIME, would optimally be seamlessly connected to early detection and treatment for manifest psychotic ill- ness (see Box 10.1).


Typically, a pre-illness period of 1–5 years exists when symptoms begin to emerge but are not yet diagnosable.

is is known as the prodromal phase. Already present dur- ing this phase are functional decline, gray matter volume loss, distressing subthreshold psychotic symptoms, neu- ropsychological impairment, and o en comorbid mood, anxiety, and substance use disorders. Insight and willing- ness to engage in treatment, however, typically remain intact and provide a window of opportunity for engage- ment into treatment. Among patients with an established diagnosis of schizophrenia, the majority retrospectively identify a prodrome. Prospective identi cation is a greater challenge. However, assessment tools have been developed to predict who may be at “ultra-high risk” or “clinical high risk” for developing a psychotic disorder, now known as psychosis risk syndrome. e psychosis risk syndrome is most commonly characterized by subthreshold positive symptoms with at least partially intact insight or reality testing, the symptoms have not reached a disorganiz- ing or dangerous level, and the frequency of symptoms is less than in frank psychosis (several minutes per day at least once a month).12 Instruments such as the Structured Interview for Psychosis Risk Syndrome (SIPS) developed by Woods, McGlashan, and colleagues in PRIME12 or the CAARMS9 are used to assess level of risk for schizo- phrenia. ree types of psychosis risk syndromes have been de ned: attenuated positive symptoms syndrome (APS), brief intermittent psychotic syndrome (BIPS), and genetic risk and functional deterioration psychosis risk syn- drome (GRD) (see Box 10.4 for diagnostic criteria12 and Figure 10.1).

e prodrome ends with the onset of frank psychotic symptoms, typically referred to as the rst episode of psycho- sis or “ rst break.” is transition is o en characterized by a loss of reality testing and insight along with some combina- tion of severe disorganization, hallucinations, or delusions. Entry to care at this stage can occur in the context of a behav- ioral crisis involving emergency services or law enforcement, and it frequently results in a forced (involuntary) psychiatric hospitalization that is o en traumatic for patients and their families.

Although investigators have variably operationalized “ rst-episode” or “early psychosis,” the rst 5 years are typi- cally considered to be a critical period or “window of oppor- tunity” for EI. Without timely connection to care, this period is characterized by repeated psychotic episodes; cog- nitive impairment; multiple hospitalizations; severe func- tional decline, o en accompanied by comorbid substance use, mood, and anxiety disorders; and substantial stress on the family and social networks. e odds for developing a severely symptomatic and functionally compromised state are substantially elevated.


Box 10.1

Early Intervention for Psychosis

Tony is a 19-year-old African American male who presented to a FES in an urban community mental health center at the urging of his parents, who had become increasingly alarmed at his unusual behavior. He had a history of good academic and social func- tion, earning above average grades, participating in sports, and spending time with friends in music-related activities. However, during his senior year of high school, his parents and friends noticed that he had become somewhat quiet, spending more time in his room alone than with others; his grades began to slip; and he did not sign up for spring baseball—a rst for him—despite his team’s likelihood of a championship year. Tony’s parents chalked this up to typical adolescent moodiness and perhaps anxiety about transitioning to college in the fall, although they also wondered if he had started abusing substances. When his friends tried to talk to Tony about what was wrong, he became uncharacteristically suspicious of their motives and accused them of collecting information for a secret website about him. He graduated high school and began attending a local university. A few weeks into the semester, Tony stopped going to class, his hygiene became noticeably poor, and he got into a verbal altercation with a professor. When his parents asked him about being home rather than at class, he became agitated, and, in the ensuing argument, his speech was di cult to follow: he made statements about being constantly monitored by video cameras, a conspiracy involving everyone he knew, and that he could hear them talking about him over radio waves. Unable to calm their son, Tony’s parents called an ambu- lance, and he was taken to a local emergency department for psychiatric evaluation. Because he was not an imminent danger to self or others and not grossly disorganized, Tony was not admitted for inpatient treatment. e psychiatric resident in the emergency department referred Tony to a local FES.

e FES contacted Tony and got permission to meet with him and his parents at their home a er Tony expressed reluctance to come in to the mental health center. A thorough assessment was completed by the team’s psychologist who determined that Tony had been su ering from auditory hallucinations of multiple voices commenting on his behavior, ideas of reference, paranoia, and disorganization at a psychotic level for 2 months with a prior prodromal period of 1 year. A diagnosis of Psychotic Disorder, Not Otherwise Speci ed was made until the psychiatrist worked in collaboration with Tony’s primary care physician (PCP) to consider secondary etiologies. Tony was also experiencing negative symptoms in the form of social withdrawal, decreased energy, and avoli- tion and cognitive symptoms of decreased executive functioning. Tony’s key clinician, a social worker, took care to engage with him around his interests in sports and music, balancing clinical material with conversations about leisure activity and social and occupational goals in their meetings. Tony identi ed that he would like most to go back to school, go back to spending time with friends, and get a girlfriend. His key clinician used cognitive behavioral therapy to address his delusional ideation and teach coping mechanisms to reduce secondary anxiety. e resulting improvement in rapport allowed her to connect him with the psychiatrist and supported education specialist. He was also encouraged to join a Social Cognition and Interaction Training (SCIT) group, and he began meeting the family clinician with his parents. A second-generation antipsychotic was started at a low dose, which Tony responded to and tolerated well. His psychiatrist and nurse carefully monitored his weight and other cardiac risk factors in collaboration with his PCP. Tony and his parents participated in Family Focused Treatment, their communication and problem- solving skills improved, and they began to better understand Tony’s illness and the diathesis-stress model. He began to feel more competent in social situations and gradually resumed going out with his friends. Tony got a part-time job and returned to school the following semester. He continued with the FES for 2 years, and, as his symptoms and functioning improved, his visits were reduced in frequency. He was subsequently transitioned to the care of a psychiatrist and therapist in his town, at which point Tony and his family felt well-educated in how to monitor for early signs of relapse and comfortable with their new caregivers.


Care for the Psychosis Risk Syndrome

In this phase of engagement, when the presence of an illness is not established, a staging approach is favored. Progressively more intensive interventions with a higher risk of potential adverse e ects are introduced as functional impairment and severity increase. Programs can tailor treatments to subthreshold symptoms and behavioral de cits and aim to

delay or prevent the onset of a rst episode of active psycho- sis. For example, mild symptoms may be treated with case management while moderate symptoms are treated with cognitive behavioral therapy (CBT). Treatment typically involves monitoring families and providing education about psychosis risk and symptoms, the diathesis stress model, and sometimes expressed emotion. Comorbid depression and/ or anxiety may be treated pharmacologically and/or with evidence-based psychotherapies (see Table 10.2).







signi cant; a er 2 years, the rate of psychosis onset did not di er signi cantly between the groups. Olanzapine was associated with signi cantly reduced psychosis risk symptoms compared to placebo; however, weight gain was also substantially higher, leading the authors to con- clude that the bene ts did not outweigh the risks. Multiple RCTs have compared time-limited CBT to an alternative nonpharmacologic intervention (e.g., supportive therapy, befriending) with variable ndings regarding the superior- ity of CBT.22 In these studies, CBT followed an empirically validated cognitive model of psychosis, was problem-ori- ented, collaborative, and included use of homework tasks and guided discovery. In one single, blind, controlled trial, CBT signi cantly reduced the likelihood of pro- gression to psychosis and antipsychotic prescription over 1 year.23 Whereas one trial comparing CBT to supportive therapy found no di erence between treatment groups at 18 months24 (both treatments were e ective in reducing attenuated positive symptoms, anxiety, and depression, thus suggesting the clinical relationship as the potentially key variable), a Dutch study comparing routine care to routine care with add-on CBT found CBT to be supe- rior for reducing conversion to psychosis and for cost sav- ing.25 CBT interventions have several advantages: they are acceptable to psychosis risk patients, make sense within a stress-vulnerability model of psychosis development, o er coping strategies that bu er against environmental stress- ors that are likely to precipitate conversion to psychosis, have shown e cacy for associated comorbidities (mood, anxiety, substance use), and target metacognition and self- schemas that are impaired in the prodrome. A RCT by Amminger compared 12 weeks of omega-3 fatty acid sup- plementation with placebo.26 A er 1 year, signi cantly few subjects in the omega-3 group developed psychosis, and there were signi cant improvements in positive and nega- tive symptoms in favor of the treatment group. Although these results are encouraging, overall, trials thus far for pre- ventative interventions have tended to be underpowered.

e large sample sizes of NAPLS, and its second itera- tion NAPLS 2, address questions of power by combining data across multiple sites. A recent meta-analysis including 1,112 subjects from 10 trials with at least 1-year follow-up concluded that preventative interventions are e ective at reducing conversion rates to active psychosis among those considered to be at high risk and that this e ect diminishes but does not disappear over time,22 Of note, subjects who do not transition to psychosis are help-seeking individuals su ering from a range of mental and social role function- ing problems and cannot simply be considered healthy false positives.19


Behavioral Adaptation


Psychotic Symptoms


Pre-Adolescence/ Adolescence

Young Adulthood

Onset of Psychosis



Figure 10.1 Typical course of psychotic illness and targets for early intervention

Only a handful of randomized controlled trials (RCTs) have been published that focus on the psychosis risk syndrome population, although there are numerous naturalistic and open label studies. e RCTs have been of antipsychotic medications, CBT, and omega-3 fatty acids. First, in 2002, McGorry and colleagues in Melbourne compared 6 months of active treatment (risperidone 1–3 mg/d plus modi ed CBT) to needs-based intervention and found that signi cantly fewer individuals in active treatment progressed to a rst episode of psychosis a er 6 months; however, the di erence was no longer signi – cant a er 1 year.20 McGlashan and Woods led the rst double-blind, randomized, placebo-controlled trial of an antipsychotic medication (olanzapine) to prevent or delay the onset of psychosis.21 In this North American trial, help- seeking patients who met criteria for clinical high risk of psychosis were randomized to medication or placebo for 1 year, followed by no medications for the second year. A er 1 year, more than twice as many placebo-treated par- ticipants than olanzapine-treated subjects had converted to psychosis, although this di erence was not statistically


Psychosis Risk Syndrome:
• Cognitive behavioral therapy (CBT)
• Antidepressant medications as indicated
• Family education and support
• Family-Focused erapy (FFT)
• Family-Assisted Assertive Community Treatment (FACT) • Supported Employment/Individual Placement and Support • Omega-3 fatty acids

First-Episode Psychosis:
• Cognitive behavioral therapy (CBT)
• Low-dose antipsychotic medications
• Family education and support
• Assertive Community Treatment (ACT) • Vocational/Educational Rehabilitation • Cognitive Remediation



Early Detection

Two systematic reviews reported a consistent association across countries between DUP and clinical outcomes.27,28 ere has thus been much interest in nding ways to decrease the time between onset of psychotic symptoms and entry into appropriate psychiatric care. e most success- ful initiative to date has been the Norwegian TIPS study. A potentially key element of the TIPS campaign to reduce DUP was its multifaceted approach. While other studies tested single outreach interventions (e.g., educating general practitioners/primary care providers), TIPS targeted both professionals who come in contact with young people as well as the general public with messages regarding how to recognize signs of psychosis, the importance and e ective- ness of early treatment, and a simple referral number, and it debunked myths regarding psychosis and treatment. e campaign utilized a variety of media and other methods, such as mailings to every household in their geographic area and mailing items with TIPS branding to general prac- titioners. ED teams based in emergency departments rap- idly responded to referrals and also assessed patients in their preferred community settings. e TIPS campaign short- ened DUP and improved long-term functioning. When the campaign was discontinued, DUP began to rise again, fur- ther supporting the conclusion that the outreach and edu- cation campaign was essential for reducing and maintaining shortened DUP.

e authors of this chapter are currently undertaking a replication of TIPS in the United States. We are interested in whether ED using similar methods, with an updated media component, can succeed in the more fragmented US health care system, with its long and complicated pathways to care. e STEP Early Detection (STEP-ED) study16 will employ a social-ecological model of pathways to care that envisions multiple sources of DUP including individual, interper- sonal, institutional/organizational, community, and social structures, policies, and systems. A key component is the use of social marketing tools to facilitate help-seeking behavior by patients and families and prompt referral by profession- als. A branding approach was used to generate a name and logo for the campaign—MindMap: A Clear Path to Mental Health (for sample materials, see Aside from the use of mass and social media, the campaign will include intensive professional outreach to various stake- holders including educational, health care, judicial, social welfare, and religious organizations. Additionally, a rapid access approach at STEP will screen and initiate engage- ment within a few days of referral and o er meetings at the point of referral, including community settings (e.g., in primary care or school counseling centers). STEP-ED

will compare a baseline year of usual detection to a 3-year campaign and a control site, a demographically and clini- cally similar FES in Boston a liated with Harvard (also an academic–public partnership), on our main outcome of DUP, as well as functional and clinical outcomes. We seek to reduce DUP through ED, gain a better understanding of pathways to care for psychosis in the United States, and determine whether or not ED improves outcomes beyond those already achieved by our FESs.

Professionals within the public sector can play a key role in outreaching and providing education to other profes- sionals who come into contact with young people, as well as participate in the development of media campaigns. ED work presents unique opportunities for psychiatrists out- side of traditional clinical, academic, and research roles and represents a clear intersection between psychiatry and pub- lic health.


Four RCTs have demonstrated the e cacy of FES in the United Kingdom, Denmark, Norway, and the United States. In the United Kingdom, the Lambeth Early Onset (LEO)29 study randomized individuals with early psycho- sis to a package of interventions including CBT, family counseling, vocational services, and low-dose antipsychotic medication all provided within community-based teams. ose receiving these more intensive services had improved social and vocational functioning, satisfaction, quality of life and medication adherence, and lower rates of relapse and dropout at 18-month follow-up. e Danish OPUS30 study o ered home-based assertive case management inte- grated with pharmacotherapy that favored lower dose antipsychotics and included family and individual psycho- education with social skills training and vocational assis- tance as needed compared to involvement with a standard community mental health team. OPUS demonstrated ben- e ts in positive and negative symptom control, secondary substance abuse, treatment adherence, and higher satisfac- tion with care in the EI condition. A Norwegian study of a similar home-based integrated approach compared to stan- dard o ce-based care reported 2-year improvements in the number and duration of hospitalizations, symptom relapse, and treatment adherence in enriched care group.31,32

e US study compared an o ce-based integrated service package (STEP) that included structured fam- ily psychoeducation, cognitive behavioral individual and group therapy, antipsychotic medications, and vocational and educational supports compared to treatment as usual (TAU) in the community.33 Patients early in the course of


a psychotic illness were randomized to STEP care or TAU. STEP patients had signi cantly fewer hospitalizations and hospital days and greater vocational engagement. is study demonstrated the feasibility and e ectiveness of a public- sector model of FES. e STEP FES was signi cantly less resource-intensive than those used in the OPUS and Lambeth studies and was still able to engender signi cant bene ts for individuals and their families.

e FES in the OPUS and LEO trials were o ered for 2 years. eir positive impact on a variety of outcomes was not detectable 3 years a er specialized care was discon- tinued. is has focused attention on an important ques- tion: how long should specialized care be o ered? STEP has implemented a less resource-intensive approach that can be sustained longer than Assertive Community Treatment (ACT) levels of care, but has also had to transfer patients a er establishing long-standing therapeutic alliances. A Canadian public-sector program successfully extended the e ects of EI by using stepped reductions in intensity to prolong care through 5 years a er entry. is is an area ripe for innovation and further study.


Just as important as what interventions are o ered is how services are o ered. e culture and values of EI teams are essential. It is important to maintain optimism and focus on recovery toward personal goals and a collaborative thera- peutic alliance. O en, patients presenting for FES may not believe that they are in need of mental health treatment, thus making engagement one of the most critical elements of care. Avoiding power struggles, connecting with patients around their interests, discussing their understanding of their experiences or illness, emphasizing patients’ goals for treatment and their de nition of recovery, exibility, and patience are some of the essential ingredients to engage- ment. e initial assessment can facilitate engagement by expanding the discussion beyond symptoms to include patient-centered metrics of quality of life, including social and vocational goals, and communicating (verbally and nonverbally) comfort with discussing unusual or bizarre material. Patients may present with disorganization or agitation that clinicians would do well to respond to with patience and validation of what that experience is like for the patient rather than immediately debating the content or explanation of those experiences. Despite initial resistance and limited or absent insight, many patients respond well if they are given an opportunity to feel heard and if the cli- nician’s perspective is only o ered a er careful assessment and, preferably, with the patient’s permission. Clinicians

should emphasize what the program or clinic can o er to match the patients’ priorities and be prepared to address confusion, stigma, or pessimism about the causes or treat- ment of mental illness.

Inclusion of family members and other naturalistic sup- ports is an essential component of FES. Families will o en be able to provide invaluable historical information dur- ing the assessment process, collaborate in monitoring the patient between clinic visits, and notice early warning signs of psychotic relapse. e emotional environment they pro- vide the patient is one of the strongest predictors of psy- chiatric relapse and hospitalization. Reducing high levels of “expressed emotion”—criticism, lack of warmth, hostility, and emotional overinvolvement—is likely to have tremen- dous bene t. Families should be treated as allies and mem- bers of the treatment team. ey may present with incorrect attributions regarding illness, be frightened, grieving the loss of a relative’s health, or agitated toward sta or the patient. It is important to keep in mind that initial meetings with families may come at what is the worst time for them. Many may have recently had a frustrating experience seeking help for their ill relative, and empathic and patient responses to their initial requests can go a long way. Reassurance, educa- tion, and communication of optimism from the clinician are useful and appropriate.

Following implementation of the RAISE Project, the NIMH issued a white paper providing guidelines for FES, “Coordinated Specialty Care.” Several treatment manuals have recently been published or are forthcoming. Consistent across most FES is the use of interdisciplinary teams to pro- vide an array of services. Various disciplines bring diverse perspectives to understanding and treating patients in a collaborative manner. Psychiatry, psychology, social work, nursing, occupational therapy, and persons with lived expe- rience with psychosis (peers) are some of the relevant actors in the interdisciplinary team. Weekly interdisciplinary team meetings and frequent communication ensure del- ity to treatment principles, facilitate morale, and encour- age high-quality service delivery. Roles are clari ed rather than rigidly assigned along disciplinary lines. For example, depending on their strengths, interests, and training, any of the disciplines can serve in the primary clinician role and assist patients in navigating the care pathway. Alternative or additional roles for the same clinician can include edu- cation and support of the family or therapy for patients in an individual or a group modality. However, the supported employment and education role requires specialized skills and signi cant time in the community to develop and to assist clients in seeking work. is role is thus less likely to be interchangeable among the clinicians. Psychiatrists or


advanced practice nurses typically provide medication man- agement, coordinate with primary care, and play a pivotal role in health and wellness monitoring and intervention. e team leader role serves to coordinate clinic activities, lead team meetings, provide supervision, ful ll administra- tive functions, oversee development and implementation of services, ensure adherence to treatment philosophies, and, sometimes, carry a caseload as primary clinician.

Many FES provide treatment in the community, similar to or following an ACT model of care. Patients are treated primarily in settings outside the clinician’s o ce, treatment teams are interdisciplinary, the sta -to-patient ratio is low, and a menu of interventions aimed at maximizing function- ing is o ered. However, unlike ACT, treatment is typically time limited (of 2–3 years duration in most programs), with step-down to less specialized services at that time. Ongoing supervision and continuing education are also important components to ensuring continued focus on FES principles and specialization.


Many treatments have demonstrated e cacy; these include CBT and low-dose atypical antipsychotic medications, and inclusion of supported employment/education and family education and involvement in a FES. Multifamily Group Psychoeducation and Support (MFG), Family Assisted Assertive Community Treatment (FACT), and Family- Focused erapy (FFT) are models for family intervention. Social Cognition and Interaction Training (SCIT), devel- oped and tested in chronic schizophrenia, is a promising approach for improving social functioning in early psycho- sis. Cognitive remediation studies have shown improved memory, social functioning, and self-esteem among rst- episode samples. Providers of FES should consider making available a menu of interventions that can be matched to patient priorities. Participation rates in group-based inter- ventions in early-psychosis samples tend to be low, and, ide- ally, patients will be returning to work or school and social involvement so that enrollment in all interventions o ered within a FES may not be realistic or desirable (Table 10.3).


EI services are designed to assertively engage and treat pri- mary psychotic disorders. Although recognizable by their characteristic symptoms and natural history, these are diag- noses of exclusion. A multitude of medical conditions and


• It is essential to have a specialized assessment carried out to determine whether the person actually meets criteria for the ultra-high-risk phase or psychosis risk syndrome.

• Monitor closely for progression to full psychosis (monthly assessments).

• Treat co-existing conditions (e.g., anxiety, depression) as appropriate.

• Provide psychosocial support, including the family.

• Recognize that youth meeting psychosis risk criteria are help- seeking and in need of care whether or not they develop a full
psychotic disorder.
drug-induced states can present with psychotic symptoms. In these cases, psychosis is “secondary” to an identi able cause that o en requires distinct treatment and sometimes referral away from an FES. Professionals working in an FES may be the rst to conduct a diagnostic assessment for a rst episode of psychosis and should remain vigilant for these secondary causes. A comprehensive medical history and examination, targeted follow-up for unusual presentations or treatment resistance, and, perhaps most important, con- tinued vigilance for the emergence of signs or symptoms sug- gestive of neurologic or other medical illnesses can reduce the risk of misdiagnosis. A er careful exclusion of second- ary causes, considerable ambiguity is to be expected in clas- sifying early-course primary psychosis. e variability in expression of symptoms and lack of an extended or reliable longitudinal history in young patients can make it di cult to distinguish between depressive or bipolar disorder with psychotic features and schizophrenia spectrum disorders. It is helpful not to wed oneself to a diagnosis with too much certainty and to encourage patients and their families to exercise the same caution while focusing on symptom con- trol, rehabilitation of functional disabilities, and continued longitudinal diagnostic clari cation (see Table 10.4 for early warning signs of psychosis).
Working e ectively within EI requires specialized knowledge of common problems encountered in early- course psychotic disorders but also a more general under- standing of the developmental psychology of adolescence and young adulthood. Samples of FEP have disproportion- ately high percentages of immigrants, trauma, substance use, suicidality, anxiety, and, particularly, obsessive compulsive disorder (OCD). For example, roughly 10% of the TIPS sample had comorbid OCD, which was associated with higher rates of suicide plans or attempts compared to FEP without OCD.34 Patients and their families will likely have questions regarding substance use and its relationship to psychosis risk; providers would do well to become familiar with the literature on cannabis use in particular. Substance



Table 10.4 EARLY WARNINg SIgNS OF PSYCHOSIS Increased di culty at school or work

Withdrawal from friends or family Di culty concentrating or thinking clearly Suspiciousness or mistrust of others Changes in the way things look or sound Odd thinking or behavior
Emotional outbursts or lack of emotion Poor personal hygiene

use in FEP is associated with higher rates of hospitalization and more severe psychopathology.

As with any aspect of public psychiatry, cultural context must be considered when evaluating and treating persons in the early stages of psychosis (see Chapter 14 for a review of cultural competence). Understanding how treatment options t within the patient’s beliefs, values, attributions, and interpretation of symptoms is an important compo- nent of culturally competent EI.

In addition to elevated rates of trauma and stressful life events among FEP populations, the experience of becom- ing psychotic is o en frightening and potentially trauma- tizing in itself. Entry into treatment can involve aversive experiences including interactions with police, physical restraint, and involuntary hospitalizations. Assessing for and attempting to alleviate fears about treatment through reassurance, education, and a patient, therapeutic stance is essential. For example, a patient may be reluctant to engage and particularly guarded due to anxiety regarding involun- tary hospitalization, but may be forthcoming if the criteria for emergency commitment are provided along with reas- surance from the professional that this is a last resort. As always, careful consideration must be given when consid- ering involuntary commitment. Although safety is the top priority, the risk of disengagement from outpatient treat- ment following inpatient discharge and the threat to the therapeutic alliance must also be considered. If hospitaliza- tion is necessary, clinicians can mitigate damage by exercis- ing principles of procedural justice (e.g., being treated fairly and respectfully, feeling heard, getting a chance to tell one’s side of the story, being included in the decision process) and, if possible, working with the inpatient treatment team and the patient on the unit. As described earlier, engage- ment is a signi cant challenge in treating FEP, and address- ing treatment-related fears in the context of establishing a trusting therapeutic relationship is an important task.

A er connection with FES, the overall prevalence of violence among FEP gradually drops to rates close to those of the general population except for patients with persis- tent comorbid substance use.35 Paranoia and persecutory delusions may also increase risk for aggressive behavior because patients may believe they are acting in self-defense. Although the majority of those in the early stages of psy- chosis will not be violent, they may still come into contact with the criminal justice system for behaviors related to symptoms, such as trespassing or disorderly conduct, and professionals working within public psychiatry will likely nd themselves interacting with the legal system regarding their patients. Understanding the local criminal justice sys- tem, as well as the ethical considerations of working with patients with legal charges or court-mandated treatment, will prove useful (see Chapter 8 for a review).

Although positive symptoms o en respond adequately to antipsychotic medication, the symptoms that can have the greatest impact on functional recovery—negative and cognitive symptoms—typically do not. Few interventions have shown e cacy in alleviating negative symptoms. Cognitive remediation programs have shown promise in reducing the intellectual de cits that typically develop in schizophrenia and, in combination with other approaches, like supported employment, might have particular promise in improving functional outcomes.36 Professionals work- ing within EI should familiarize themselves with the com- mon cognitive symptoms associated with psychosis, such as executive functioning de cits, and consider referral for neu- ropsychological assessment. Such an assessment can both evaluate the extent of dysfunction compared to population norms, monitor for changes over time, and suggest strate- gies to reduce their impact on school and work function.


e work described in the preceding sections is better seen not as a speci c set of interventions but rather as a para- digm of approaching a set of diseases that, like many other serious mental illnesses, have their onset in late adolescence and early adulthood. Although the primary psychotic dis- orders are believed to be heterogeneous in etiology and pathophysiology, the organizing exemplar of schizophre- nia provides a rational focus for this paradigm. Speci cally, e orts to investigate and care are guided by the knowledge of these as neurodevelopmental illnesses with possible in utero causal factors, identi able but imprecise markers in childhood, and reliable recognition in full-blown psychosis during early adulthood. Although the needs of patients and



families can now be anticipated and outcomes demonstra- bly improved a er the FEP, much work needs to be done to better predict and prevent the onset of psychosis in those at risk. Furthermore, the identi cation of biomarkers that predict illness onset could provide opportunities for selec- tive and even universal prevention. ese aspirational goals illustrate the goals of this paradigm, one that brings psy- chiatry into the mainstream of public health and medical practice.

is paradigm requires close relationships between the activities of research and clinical care. Both PRIME and STEP have enabled the recruitment of patients and fami- lies into a variety of investigations across the translational continuum—from genetics to policy—while also allowing patients access to cutting-edge interventions and knowl- edge. is platform for innovative research and care has also been an attractive training site for social work, psychol- ogy, anthropology, and psychiatry trainees. While possible in other settings, the public–academic collaboration at the core of this work has been pivotal in allowing innovative models of care and research to be supported in ways that are not yet possible in fee-for-service environments.

EI clinics also provide the opportunity to prevent comorbidities associated with shortened life span in chronic schizophrenia. Relative to their peers without seri- ous mental illness, patients with schizophrenia experience a threefold increase in cardiovascular mortality between the ages of 18 and 49 and an almost twofold increase in mortality between the ages of 50 and 75 years. Although this increased disease burden is likely multifactorial, per- sons with schizophrenia have a higher prevalence of several modi able risk factors for cardiovascular disease including smoking, obesity, diabetes, dyslipidemia, and hyperten- sion. Long-term use of antipsychotic medications may play an important role in the increased risk for cardiovascular diseases because antipsychotic medication use is associated with signi cant weight gain, dyslipidemia, and insulin resis- tance. In contrast to the consistently poor cardiovascular risk in chronic schizophrenia, studies of rst-episode psy- chosis samples have been inconsistent. Given discrepancies in the reported prevalence of cardiovascular risk factors in early-psychosis samples, STEP compared FEP patients with minimal prior antipsychotic exposure with age-, gender-, and race-matched peers drawn from the National Health and Nutrition Survey on 10-year cardiac risk. Although indistinguishable from peers at entry, patients su ered per- vasive adverse trajectories of cardiovascular risk factors over the subsequent year due to higher rates of nicotine depen- dence and obesity. Similar adverse trends in blood pressure, lipids, and fasting glucose led to an increase in prevalence of

the metabolic syndrome.37 ese ndings provide a rational focus for prevention of premature cardiovascular mortality. e rst year of treatment constitutes the beginning of a critical period for such preventive e orts. Public psychia- trists have the opportunity to intervene early with young patients on health and wellness behaviors before harmful habits set in, collaborate with primary care to assure that their patients do not follow the typical pattern of disengage- ment, and play a role in reducing premature cardiovascular mortality (see Chapter 5 for a review of health promotion strategies).


Much progress has been made over the past quarter century in understanding how to implement the two major domains of EI in psychosis: the early detection and e ective care of young patients and their families. e goals of prevention have so far been limited to exploration of possible indicated prevention in selected high-risk samples, and the state of the art might better be conceptualized as early treatment for those who are seeking help for signi cant psychological distress or social dysfunction that only in some cases will result in the diagnosis of a psychotic disorder but in most cases merits clinical attention.

Outcomes for psychosis are indeed better when inter- ventions are delivered early or when they are delivered by a specialized team, but this is not usually the case on transfer to regular care systems. Also, EI is not widely available in the United States. In other words, there is still a long way to go for the goals of EI to be realized. What tasks and ques- tions remain for future public psychiatry professionals?

We will answer this question by addressing two other broad questions that we hope will engage the novice entrant to public psychiatry. First, how can we continue to increase our understanding of how to prevent and, when this is not possible, rapidly intervene to meaningfully improve out- comes for patients with psychotic disorders? Second, how can we engage with stakeholders outside the health care community to extend the reach and impact of empirically validated service models on public health?

e NIH focus on mechanisms and circuits that are agnostic to current phenomenology-based classi cation (e.g., DSM 5) might deliver new insights on common vul- nerabilities (e.g., working memory de cits, social cogni- tion impairments) and mechanisms of disease progression. is could lead to better causal discrimination of various psychotic illnesses and provide rational targets for pre- ventive approaches and more targeted pharmacologic and


psychosocial treatments. e psychosis risk syndrome was not included in the DSM 5 as a diagnostic category due to controversy surrounding false positives and concerns that assigning this diagnosis would be both stigmatizing and lead to even greater inappropriate prescribing of antipsy- chotic medication. e countervailing argument is that prodromal psychosis may currently be misdiagnosed as depression or attention de cit disorder, and inappropri- ate treatments might be worsening clinical outcomes. e question of how best to categorize developing and hetero- typic adolescent psychopathology is thus ripe for empirical investigation. e large sample sizes in the NAPLS stud- ies continue to contribute to this debate and have already facilitated improved models of prediction.13 Improving our ability to predict the onset of psychosis will allow us oppor- tunities to reach back earlier in the trajectory of disease pro- gression and test approaches to indicated and, theoretically, perhaps even to selective or universal prevention.

In the domain of treatment of manifest illness, even the most e ective EI services cannot succeed unless youth in early stages of psychosis are reached and engaged. In Australia and the United Kingdom, EI research programs have advocated for and are seeking to embed themselves within broader youth mental health service models (e.g., Headspace, Youthspace). e United States also may need to consider this approach. In keeping with the reality that most serious mental illnesses are chronic diseases of the young,38 this model could li all boats by providing a less stigmatizing entry point into care not just for schizophre- nia spectrum disorders, but also for bipolar disorder, sub- stance use disorders, and depression. At the federal level, the SAMHSA has recently shown an interest in such an approach with its Healthy Transitions initiative in sup- port of the President’s “Now Is the Time Plan.” Healthy Transitions places emphasis on engagement and aims to improve access to treatment and support services for youth at risk for serious mental illness.

Another unresolved issue is how long FES services should be continued or how their bene ts can be sustained on transition to less intensive models of care. Given that these disorders, like most chronic illnesses, are not cured by current treatments, it should not be a surprise that some e ects are not durable a er 2–3 years of specialized care, and di erent health care systems will have to test models that allow more tailored and economically sustainable transitions into less intensive services that can maintain and even advance the positive trajectories delivered by EI services.

Although there is much to learn about disease mecha- nisms, best clinical practices, and models of service delivery

to improve our success at prevention and EI, there is already much in the “toolbox” that clinicians and administrators can draw upon to improve population outcomes today. Described by some commentators as the challenge of knowledge translation,39 this involves work further “up” a translational continuum that begins at the genetic level and ends in public policy. e developing professional in public mental health would do well to be at least conversant with the multiple languages spoken at the di erent levels of anal- yses. Of particular relevance to public psychiatry is the abil- ity to communicate the public health bene ts of treatments or service delivery models to a wide variety of stakeholders with distinct and valuable perspectives and roles in human well-being. e novice in this heterogeneous arena should guard against two common seductions that can oversim- plify into ideology what is better accomplished by negoti- ated and empirically driven change. On the one hand, the logic of bureaucracy might weigh in the direction of stasis and resist disinvestment and reallocations of resources from legacy services to make way for newer approaches. On the other hand, the logic of the marketplace can confuse an overly narrow emphasis on nancial cost to one stakeholder (e.g., hospital bed days) with true health economic merit, which requires a broad societal perspective (loss to the labor market, judicial costs, entitlement costs). Although health care “cost” has rightfully become an important focus in US health care policy, the mental health professional would do well to familiarize him- or herself with the broad soci- etal perspective of health economics.40 Between these two extreme positions, novel programs might be asked to answer to a higher standard of evidence than legacy practices or present a cost-saving solution to one agency while ignoring wider economic bene ts. To be an informed advocate, the young professional can draw on her clinical skills in build- ing rapport and listening to diverse points of view to engage and educate herself about how to interact within complex organizations.41 She might also educate herself on current concepts of value in health care that seek to orient resource allocation decisions toward those services that maximize “health outcomes achieved per dollar spent”42 and extend the focus beyond existing patients to population health,43 which is in keeping with the ethos of public psychiatry. In the United States, where the presence of multiple payers creates incentives for the cost-shi ing of non-reimbursable but high-value activities, creative nancial mechanisms will be necessary to realize health care value. A recent proposal for funding EI in the United States is illustrative of how these challenges might be addressed.43

Although the funding mechanisms for EI are clearly in their infancy in the United States, there are grounds for




A. Access

A.1 Rapidity

A.2 Equity

A.3 Coverage

A.4 Pathway to care

B. Engagement

B.1 Overall B.2 Quality

B.3 Exposure to family education

B.4 Exposure to peer/social skills

C. Outcomes

C.1 Hospitalization C.2 Remission

C.3 Recovery

C.2 Vocational Engagement

C.3 CV Risk (a) Smoking

(b) Overweight or obesity


Achievable (30%); Aspirational (75%)
Achievable (50%); Aspirational (75%)
Demographics will match 2010 Census for local region served

Achievable (15%); Aspirational (80%) Achievable (60%), Aspirational (30%)

Achievable (70%); Aspirational (90%)
Assess along 4 domains and across A.2 groupings for disparities

Achievable 75%; Aspirational 90% of patients will have had at least one caregiver attend at least one meeting

Achievable 75%; Aspirational 90% of patients will attend at least one meeting

Achievable (<25%); Aspirational (<10%)

PANSS 8-item score ❤ at 6 months: Achievable (50%–70%); Aspirational (85%)

PANSS 8-item score ❤ at 1 year: Achievable (80%); Aspirational (90%)

75% are at level 8 or better on both Achievable (85%); Aspirational (90%)

Achievable (20%); Aspirational (10%) Achievable (60%); Aspirational (30%) Achievable (30%); Aspirational (75%) Achievable (60%); Aspirational (75%)


As EI services mature, so should the standards for measur- ing success. Clinical trials provide opportunities to exam- ine in great detail areas of symptom severity, social and occupational functioning, duration of untreated psychosis, quality of life, physical health, adverse e ects, treatment engagement, and so on. However, routine clinical practice should also examine e ectiveness in an ongoing manner to


DUP 1 ❤ months DUP 2 <12 months

Proportion of females, ethnic groups, town of residence, age

Number annually o ered STEP/Expected annual incidence

Proportion admitted a er hospital admission

In contact with STEP at 1 year Service Engagement Scale Exposure to FFT

Exposure to SCIT

Admission to Psych unit in 1st year Positive psychotic symptoms

global Functioning-Role & Social scale

In at least part-time school or work or actively looking for vocational opportunities (e.g., engaged in supported employment)

New smokers at 1 year Smoking rate at 1 year BMI < 25 at 1 year
Retain BMI WNL at 1 year


optimism. e UK National Health Service, which has pio- neered the use of cost-utility analyses to inform investment in health care interventions, has already made a signi cant commitment to FES and adds credibility to the economic rationale for EI. Also, in the United States, the SAMHSA, for the rst time in 2014, required 5% of its mental health block grants to be allocated to FEP in all states, thus signal- ing a small but signi cant indication that such services may become part of the landscape of usual care in this country.


allow for course corrections and examination of potential shortcomings in treatment delivery. A benchmark model whereby FES would regularly audit and compare itself to international standards is advocated by the authors of this chapter. Although traditional assessments of delity to a particular model of care can be useful for the purposes of training in technical interventions and disseminating appropriate cultures of practice, these process-oriented approaches do not directly address value; that is, the degree to which population outcomes are improved for a speci c investment in resources. In STEP, we favor ongoing exami- nation of benchmarks as a way of alerting us that changes to our service delivery or interventions may be necessary. See Table 10.5 for a putative sample of benchmarks based on STEP’s past outcomes and a review of the international outcomes literature. ese are not meant to be comprehen- sive or even prescriptive, but to illustrate what a standard of care might mean for an EI service and allow transparent communication to patients and families: for example, “If you come to our service you can expect a higher than 85% chance that you will be vocationally engaged in 1 year.”


It is an exciting time to be entering the eld of public psy- chiatry. e promise of early intervention in schizophrenia is being realized, yet much work remains in order to fully achieve prevention of illness and its harmful e ects. Public psychiatry plays an important role in EI, where much of the services are likely to take place, and in addressing a tremen- dous public health and human burden. Professionals who decide to specialize in EI will be rewarded with participating in their patients’ recovery to more satisfying lives than pre- viously thought possible, and they will assist in the develop- ment of cutting-edge treatments and their implementation.

Although the evidence base for EI is compelling, more work is needed to re ne and extend the impact of EI models. is includes studying and adding re nements to existing FES that are informed by a better understand- ing of disease pathophysiology but also improving the rate at which empirically supported models are implemented to reduce morbidity and mortality. e varieties of pro- fessions within public psychiatry, including social work, nursing, psychology, and psychiatry, can play an important role in advocating for the delivery of existing best practices to this vulnerable population. Optimism is warranted, given growing success by many developed economies in realizing the promise of EI and the more recent focus by the NIH and SAMHSA in disseminating FES across the

United States. e building of robust systems of care for early psychosis will reduce su ering now, but can also pro- vide a valuable platform from which to study and develop improved approaches to treatment and even prevention. For the trainee in public psychiatry, this is an excellent time to enter an area that o ers opportunities for mean- ingful engagement in clinical work, research, policy, and workforceeducation.


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29. Tempier R, Balbuena L, Garety P, et al. Does assertive community outreach improve social support? Results from the Lambeth Study of early-episode psychosis. Psychiatr Serv. 2012;63(3):216–222.

30. Secher RG, Hjorthoj CR, Austin SF, et al. Ten-year follow-up of the OPUS specialized early intervention trial for patients with a rst epi- sode of psychosis. Schizophr Bull. 2014;41(3):617–626.

31. Malla A, Norman R, Schmitz N, et al. Predictors of rate and time to remission in rst-episode psychosis: a two-year outcome study. Psychol Med. 2006;36(05):649–658.

32. Malla A, Norman R, Bechard-Evans L, et al. Factors in uencing relapse during a 2-year follow-up of rst-episode psychosis in a specialized early intervention service. Psychol Med. 2008;38(11):1585–1593.

33. Srihari VH TC, Kucukgoncu S, et al. First-episode service for psy- chotic disorders in the US public sector: a pragmatic randomized controlled trial [published online January 15, 2015]. Psychiatr Serv. 2015;66(7):705–712.

34. Hagen K HB, Joa I, Larsen TK. Prevalence and clinical character- istics of patients with obsessive-compulsive disorder in rst-episode psychosis. BMC Psychiatry. 2013;13:156–162.

35. Langeveld J, Bjorkly S, Auestad B, et al. Treatment and violent behav- ior in persons with rst episode psychosis during a 10-year prospec- tive follow-up study. Schizophr Res. 2014;156(2–3):272–276.

36. Allott KA, Cotton SM, Chinnery GL, et al. e relative contribu- tion of neurocognition and social cognition to 6-month vocational outcomes following individual placement and support in rst- episode psychosis. Schizophr Res. 2013;150(1):136–143.

37. Srihari VH, Phutane VH, Ozkan B, et al. Cardiovascular mortality in schizophrenia: de ning a critical period for prevention. Schizophr Res. 2013;146(1–3):64–68.

38. Insel TR, Fenton WS. Psychiatric epidemiology: it’s not just about counting anymore. Arch Gen Psychiatry. 2005;62(6):590–592.

39. Straus SE, Tetroe J, Graham I. De ning knowledge translation. CMAJ: Can Med Assoc J. 2009;181(3–4):165–168.

40. Meltzer D. Perspective and the measurement of costs and bene ts for cost-e ectiveness analysis in schizophrenia. J Clin Psychiatry. 1999;60(Suppl. 3):32–35; discussion 36–37.

41. Perrow C. Complex Organizations: A Critical Essay. Echo Point Books & Media; Second Edition. Glencoe, IL; Sott, Foresman. USA. 2014. 42. Porter ME. What is value in health care? N Engl J Med.

43. Gray JA. Better value healthcare—the 21st century agenda.

Zeitschri fur arztliche Fortbildung und Qualitatssicherung.





Charles C. Dike, Marc Hillbrand, Richard Ownbey, Daniel Papapietro, John L. Young, Srinivas Muvvala, and Selby C. Jacobs


• From the late 19th century to the mid-20th century, state hospitals, most with thousands of residents, provided accommodation and treatment for all hospitalized individuals with mental illness.

• A combination of political and legal mandates, in addition to the discovery of chlorpromazine, led to deinstitutionalization of state hospitals, with a corresponding precipitous decline in both the number and population of state hospitals.

• State hospitals now serve as the receptacle for the most challenging patients from community mental health agencies and general and tertiary hospitals.

• State hospitals house the most severely ill patients who present a high risk of danger to others or themselves, are gravely disabled by their illness, or are under legal commitment or hold to the hospital.

• Treatment planning is by a multidisciplinary team of professionals with the patient and his or her advocates or family members at the center of decision-making regarding the patient’s treatment.

• Individualized, recovery-oriented, patient-centered treatment driven by legal and patient advocates has limitations for a select group of patients.

• Agencies such as the Joint Commission, the Center for Medicare and Medicaid Services, the Department of Public Health, and the US Department of Justice monitor and regulate treatment practices in state hospitals.

• State hospitals should develop metrics for evaluating and monitoring the quality of care provided.


In the 1840s, human rights activist Dorothea Dix proposed that the mentally ill should be treated in a more therapeutic and humane manner than was the current practice, which was primarily custodial. Her in uence was considerable. By the beginning of the 20th century, dozens of state psy- chiatric hospitals had been built in the United States, some populated by thousands of persons with severe psychiatric disabilities. In the United States and much of the Western world, these men and women were from then on treated

according to an institutional model of o en life-long inpa- tient care. e legal foundation for these commitments, most of them involuntary, was o en questionable.

State psychiatric hospitals were self-su cient communi- ties where land was farmed by sta and residents and where cattle were raised. Most sta resided in hospital housing. Many hospitals were built at some distance from existing towns. An important function of this arrangement was rid- ding the community of its most unruly citizen, a function not unlike that served by jails and prisons.1,2 For instance, at Connecticut Valley Hospital in Middletown, Connecticut,


Figure 11.1 Connecticut Valley Hospital, in Middletown Connecticut: Aerial View of the Campus

built in the 1870s, the 5,000-plus residents and sta were early “locavores.” Each ward and each department received fresh, warm (unpasteurized) cow’s milk daily, delivered by residents who had a job on the hospital farm. e same was true of fresh bread, baked daily in the hospital’s oversized kitchens. is practice did not end until the late 1950s, when the ethics and legality of employing hospital resi- dents without adequate compensation came into question (Figures 11.1 and 11.2).

In spite of some strengths, such as the focus on rehabili- tation through work, this system of institutionalization suf- fered from uneven care, inadequate sta ng, and o en poor living conditions.3 Deinstitutionalization emerged as an outgrowth of the National Mental Health Act of 1946.4 e e orts to humanize the care of the severely mentally ill were made possible by the discovery of the antipsychotic bene ts of chlorpromazine and other drugs. e National Mental Health Act funded the newly created National Institute of

Figure 11.2 Architectural Designs of State Hospital Buildings

Mental Health and set the research agenda of uncovering the causes of mental illness and developing treatments for it. e Mental Health Study Act of 19555 then led to the establish- ment of the Joint Commission on Mental Illness and Mental Health. e Commission’s 1961 report listed concerns about civil rights violations and poor living conditions in state hospitals and became the basis of the Mental Retardation Facilities and Community Health Centers Construction Act of 1963,6 also referred to as the Community Mental Health Act. e Act is the foundation of the community mental health model of care, one of President Kennedy’s New Frontiers. Prior to the era of community psychiatry, which began in 1963, state psychiatric hospitals provided virtually all hospital-based care, both acute and long-term. In the past 60 years, as a result of deinstitutionalization, bed capacity in state hospitals has declined precipitously as states redirected their resources to community-based care.7 Consequently, state hospitals currently devote few if any of the currently available beds to acute care. Coincident with this decline in acute state hospital beds, the enactment of Medicare8 and Medicaid in 19659 nanced an enormous expansion of acute care psychiatric beds in general and com- munity hospitals (Medicare and Medicaid Title XVIII, and Title XIX of the Social Security Act). In 2008, Congress also enacted parity of insurance coverage for mental disor- ders through Medicare and private commercial insurance, thus reinforcing this development (Mental Health Parity and Addiction Equity Acts of 2008).10

On the other hand, managed care, utilization review, and scal problems in hospitals over the past 20 years have considerably eroded the number of acute beds in general hospitals (see Chapter 2; AHA reports 200711, 201212). Furthermore, managed care, sometimes in violation of the federal law parity provisions, reduced the length of stay in acute beds to an average of 7.2 days by 2010, accord- ing to the national hospital discharge survey conducted by the National Center for Health Statistics.13 In response to these scal and management pressures, as well as a function of “services research” testing their e cacy, alternatives to hospitalization have emerged such as partial hospital units, intensive outpatient programs, and crisis-respite programs. All these are frequently paired with residential services (see Chapter 4 on Housing). In short, the net result, rst noted in an appendix of the New Freedom Commission Report in 200314 and heralded in American Hospital Association publications since 2007, is that there is now a shortage of acute psychiatric beds across the United States, and this presents a crisis for general hospital emergency departments (EDs) that struggle to nd suitable therapeutic settings to admit acutely ill psychiatric patients.

e A ordable Care Act of 201015 reinforces many of the trends discussed brie y so far. Health services research must be directed toward globally assessing both inpatient and outpatient mental health capacitates, developing clini- cal standards and protocols for each level of service and reducing gaps within the system of care, and improving development of e ective interventions to prevent and man- age behavioral crises in the community, such as investing in expansion of urgent care and crisis intervention programs.16 A reason to be hopeful about general hospitals’ future investment in psychiatric care is the recent change in atti- tude within hospitals, aptly captured by the dictum of the Surgeon General of the United States: “there is no health without mental health.”17


As a result of the developments just reviewed, over the past two decades, acute hospital care essentially has become intensive care. It focuses on rapid evaluation, prompt insti- tution of treatment, management of risk, and concomitant discharge planning to transition patients to step-down care as soon as possible.

e clinical competencies required to work on acute care units are core clinical skills learned in basic professional training. ese are re ned to address the needs of people with serious mental illnesses and addictions at the height of symptomatic severity. Given the nature of admissions to acute care units, risk assessment is essential (see Chapter 8). In order to step-down care, clinicians must exercise profes- sional judgment to assure that the risk of danger to oneself or others is manageable. Also, given the number of involun- tary admissions, issues of informed consent about treatment are common, and e orts to establish cooperative, voluntary, clinical relationships are essential. In addition, on special- ized units such as those treating children and young adults or individuals with eating disorders or traumatic brain injury (TBI), expertise in those diagnostic categories or age groups is vital.

Professional sta ng of acute care hospital units includes physicians, psychologists, nurses, social workers, counselors, and other support sta who work as members of an interdis- ciplinary team (IDT). Medical sta guidelines for the hos- pital, including policies of hospital nursing and social work departments, de ne the roles of behavioral professionals. ese roles include traditional hospital functions such as special diagnostic services, prescribing treatments, 24-hour nursing care, and discharge planning. Given the time pres- sures created by short lengths of stay, the IDT must function


e ciently, usually with a division of labor and o en under the eye of a hospital administrator monitoring its pro- ductivity and quality. Despite these constraints, skilled, acute-care professionals strive to develop person-centered plans of care that take into account the wishes of people with serious mental illnesses and addictions and set the direction for continuing ambulatory care (see Chapter 3). Consistent with person-centered care, acute-care profes- sionals in hospitals are incorporating the recovery model and patient- and family-centered care (PFCC) approaches into the planning and delivery of mental health care (see Chapter 3 on Recovery model).18,19 PFCC improves the experience of care and outcomes by ensuring that this care revolves around the needs and wishes of patients and their families. is is achieved by actively involving patients and their families both in clinical care planning and in policy and program development within the organization.

For acute hospital units to operate e ectively and main- tain safe, therapeutic, and e cient ow of referrals and dis- charges, they must establish collaborative interfaces with a variety of clinical programs both within the general hospital and in the public arena of community services. Regarding admission, the acute care hospital must be responsive to its own ED, which is o en working over census, with high demand and slow transfers into the hospital. Some EDs are equipped with observation beds/units that serve as an inter- mediate placement while awaiting disposition. Although urgent care services (also known as crisis intervention units) are a frequent source of referrals into the hospital, they also help to avoid hospitalizations through the provision of e ective, early interventions and placement into respite and residential care. Sometimes this diversion is critical in man- aging periods of heavy demand, and it is always useful in considering less costly yet safe, e ective plans of care.

During hospitalization, the psychiatric consultation service, backed up by the acute inpatient service, responds to other hospital medical units on which acute psychiat- ric problems arise, sometimes transferring patients to the psychiatric unit when a behavioral problem cannot be managed in a scatter bed. Reciprocally, when a psychiat- ric admission develops an acute medical crisis, transfer to a medical unit for treatment may occur. e possible syn- ergy between medical care and behavioral health care rarely leads to mutually supportive programs in recognizing and e ectively treating the co-occurring conditions on both sides of the health divide. Going forward, the increasing co- occurrence of medical illnesses among psychiatric patients and behavioral health problems among medical patients demands creative approaches to the co-management of these conditions.20

At the end of a hospitalization, it is essential for the acute care unit to have well-developed links to the systems of ambulatory and community-based care.21 O en, acute care units step-down to partial hospital or intensive outpa- tient programs. Discharge into ambulatory care typically occurs to a community behavioral health center or com- munity health center (federally quali ed health center). In each of these cases, the person being transferred enters a dif- cult transitional period that must be managed as well as possible by both sides of the continuum of care.

Sometimes, in cases with unremitting acute symptoms or an unabating risk of danger to self or others, it is impos- sible to step-down care. In these cases, the acute care unit must maintain a boundary with long-term care beds, typi- cally in public hospitals or in specialized units for forensic problems, substance abuse rehabilitation, or residential pro- grams for youth.


Emergency services provide care for those in extreme states of distress or emergent changes in mental status. ey con- gregate a variety of essential capacities that make them unique entities in general hospital function. ey are one of the few places where the full range of the technical and per- sonnel resources of the institution can be focused quickly and e ciently on the needs of patients and where decisions about ow and destination can be made. Not only do the ED and colocated behavioral health emergent services have the personnel to address major and urgent physical needs, they also have the mental health resources to handle the evaluation, brief treatment, and dispositional needs of a variety of mental health and substance abusing patients. e ED functions as the valve regulating ow to scarce resources, holding patients who require admission until a bed comes free, diverting patients to appropriate commu- nity and institutional outpatient services, and coordinating care by helping patients make the connection to the next best level of care for their needs.

As such, with a diversity of tasks, the ED must have a diversity of personnel with the expertise to carry out those tasks required. Physicians need to be present or quickly available, and advance practice nurses and phy- sician assistants must also handle evaluations and thera- peutic needs. It is essential to have specialized psychiatric nursing sta with psychiatric back-up skilled in handling behavioral emergencies. Social workers help manage the collateral contact and the dispositional resources for


community-based referrals. Other ancillary sta and pro- tective services also help keep the milieu safe and thera- peutic despite the acuity of the presentations to the ED. ese behavioral health professionals, drawing in part on psychiatric consultation skills, work in close collabora- tion with medical colleagues in the ED to ensure that the patient’s essential medical needs are taken care o along with his or her mental health needs.


People with serious mental illnesses and addictions tend not to respond rapidly to acute interventions. ose who do not respond to acute hospitalization, who cannot be referred into community care, and who require longer term care are referred to the state hospital. e majority of people are admitted under emergency physician orders or probate commitment, for substance abuse-related issues, or for identi ed forensic issues such as restoration to com- petency, not guilty by reason of insanity (NGRI), or other court-mandated issues. Although attempts are made to address these patients’ needs on an outpatient basis, the population in need of inpatient care presents increas- ingly with multiple and signi cant challenges in multiple domains. As with the general population, they are aging and have more medical comorbidities. Many su er from comorbid substance abuse, personality disorders, and medical illnesses such as obesity or renal, hepatic, cardiac, and pulmonary disorders. Many are treatment nonadher- ent or frankly treatment-resistant. ey are challenged with a lack of resources, cognitive impairments (either as a result of their illness or secondary to medication side e ects), social and familial estrangement, housing and employment de cits, and negative symptoms of chronic psychosis that make cooperative access to care challenging.

e patients in state hospitals usually enter because of imminent risk of danger toward self or others or because of grave disability leading to an inability to care for them- selves. Even with patients who are not in imminent danger of acting aggressively, frequently, the signi cance of their aggression history creates challenges for discharge from the hospital. Problematic clinical presentations include repeti- tive self-injurious acts or suicide attempts; a past history of having acted on dangerous command hallucinations, especially if the psychotic disorder is treatment refractory; a sex-o ending history with ongoing sexual urges that are ego-syntonic in a patient without treatable psychotic or mood disorder; and dangerous and severe personality disorders.


By virtue of state hospitals being the repository of refractory mental illnesses of all kinds, subspecialty areas have devel- oped. ese include dual-diagnosis units for substance abuse and mental illness, geriatrics, child and adolescent, and foren- sic subspecialties. In addition, some hospitals have traumatic or acquired brain injury treatment units, and sexual o end- ers’ treatment units. Although not a predictable cohort, there are the inevitable admissions of people who do not t in other systems. is group is almost always very violent, cognitively challenged, and poorly responsive to psychophar- macologic or psychotherapeutic interventions. Some do not present with diagnosable major mental illness but instead are impaired by severe character pathology that makes them violent and unmanageable in settings other than prison; intermittent short-lived symptoms of psychosis or mood dis- order that accompany their character pathology leads to their incarceration in state hospitals rather than prison.

e common characteristic of the special population of patients needing hospitalization in the state hospitals is the long period of time needed to manage their symptoms suf- ciently enough to ameliorate the risks of danger that they pose to others in the community (as well as risks of danger to themselves). With the exception of those patients admit- ted for competency restoration who must be returned to court as soon as they regain competency, state psychiatric inpatients o en require specialized and prolonged treat- ment interventions and, even then, show only incremental improvement of symptoms at a slow pace. Some may never recover enough to be considered safe in the community, whereas some others, such as sex o enders, evoke such neg- ative response from the community that discharge to the community becomes a nearly impossible task. As a result, the length of stay in state hospitals varies widely from sev- eral months to decades. Although most of the longest stay patients are those under some form of legal mandates to be hospitalized (e.g., NGRI), some civil patients remain so di cult to manage in any other setting that they require inpatient treatment for many years.


Given the long duration of stay in state hospitals, ancillary services such as internal medicine, dentistry, neurology, gynecology, optometry, and podiatry play an important role. Ideally, the services are provided on-site, given the patient population’s resistance to or refusal of care and the


risk of transporting them to medical centers or local hospi- tals. Additionally, the specter of patients arriving or sitting in waiting rooms of medical centers or acute care general hospitals in restraints and with security sta in close atten- dance due to their risk of danger to others or of elopement further tarnishes the image of psychiatric patients and decreases the willingness of outside medical sta to treat them. It would, therefore, be prudent for state hospitals to contract with specialty medical services to provide care for these patients on the grounds of the state hospital where they can be safely managed. In that vein, some state psychiat- ric hospitals have dialysis and nephrology services available on site. Furthermore, a psychiatric hospital will inevitably have emergency situations that necessitate access to a gen- eral hospital ED for assessment and treatment. In such situ- ations, the presence of a general hospital nearby is invaluable because transporting the patients long distances could pose additional safety as well as medical risks (Figure 11.3).



As a general rule, the attending psychiatrist is the clini- cal leader of the treatment team22 in the state hospital. e

psychiatrist’s role is to coordinate the care of the patients by integrating the assessments of the various disciplines into generating a di erential diagnosis and a coherent plan of care that incorporates the ndings of other members of the team. During the treatment planning meeting, the psychiatrist assumes primary responsibility for the individual’s treatment; requires that the treatment team function in an interdisci- plinary fashion; ensures that the patient’s advocates, other clinical sta , and outside agencies (as necessary) have been invited to participate; and ensures that the individual patient is treated with dignity and respect. e psychiatrist ensures that the patient has a substantial and identi able input into the treatment plans, is informed about the purposes and side e ects of prescribed medication, is informed of pertinent results of investigations and consults ordered, and is an active participant in the discharge planning process.

e psychiatrist ensures that all team members par- ticipate in the development, monitoring, and, as necessary, revision of treatments. In addition to the patient, any family members present or other advocates are encouraged to par- ticipate in the discussion of treatments, and all discharge- related objectives are reviewed and required changes to interventions are considered. In addition, factors that might a ect treatment outcomes, including age, gender, culture, and treatment adherence, should be discussed as relevant in the plan of care.

Figure 11.3 Dental Department within the Grounds of a State Psychiatric Hospital

e psychiatrist works collaboratively with a general medicine practitioner (including family practitioners, advanced practice psychiatric nurses [APRNs], etc.) for the treatment and monitoring of medical issues, including side e ects of psychotropic medications. It is important to note that the psychiatrist is the physician of record in charge of patients under his or her care, and the role of the general medicine practitioner is consultative. e psychiatrist must be alert to consult the services of the general medicine prac- titioner as needed and ensure that recommendations are promptly carried out. If the psychiatrist is not satis ed with the recommendation of the general medicine practitioner, the psychiatrist is obliged to seek additional consultation from other providers and communicate with them as nec- essary in order to address a patient’s physical health needs. ere should be no confusion as to who bears the ultimate responsibility for the care of the patients: the attending psy- chiatrist. Of course, the general medical practitioner also bears some responsibility if a negative outcome related to physical health issues occurs.

With regard to risks, the psychiatrist has statutory responsibility and liability risks for judgments about sui- cide and risk of danger to others. Sometimes, other profes- sionals with a license to practice, such as nurses and social workers, may share in the risk of liability depending on the speci cs of the case. Risk assessment is a critical function of the attending psychiatrist (in conjunction with other mem- bers of the treatment team), the results of which determine a patient’s access to privileges and movement within and outside the hospital. Some state hospitals employ the ser- vices of consulting forensic psychiatrists experienced in risk assessment to assist the attending psychiatrist in decisions regarding the movement of dangerous and o en legally involved patients into the community or to community placements.


Nursing as a discipline coordinates all aspects of the patient’s care, reviews issues that arise in the milieu, actively engages with the individual in providing treatment interventions as outlined in the patient’s plan of care, and provides sup- port and empathic listening. ese interventions further assist in the development of a therapeutic relationship. e nurse continues to assess the individual’s response to actual and potential health concerns and provides evaluative data derived from the nursing process prior to the development of the treatment/recovery plan.

Essential nursing inter ventions include counseling , including crisis intervention; management of the therapeutic

environment; assisting with self-care activities; administer- ing and monitoring psychobiological treatments; health teaching, including psychoeducation; providing culturally relevant health promotion, maintenance, and disease pre- vention strategies; case coordination; and assisting with skill acquisition.

e nurse documents nursing interventions planned to facilitate goals and objectives. e interventions take into consideration the individual’s likes, dislikes, and per- sonal preferences. e interventions are speci c enough to provide concrete directions for the patient’s nursing care providers.


e APRN functions in an increasingly important role on the inpatient unit. e APRN can function as a colleague to the psychiatrist in prescriptive treatment as well as psy- chotherapeutic (group or individual) interventions. As clinical nurse specialists, advanced practice nurses may also serve as a resource for the clinical education and supervision of the nursing sta , even as they serve an important bridg- ing function between the nursing sta and other members of the team.


e rehabilitation therapist assigned to the treatment team is responsible for presenting the information derived from the rehabilitation assessment, including the patient’s educa- tion level; employment status; cognitive skills; social, rec- reational, and leisure activities; life skills; interpersonal and communication skills; coping skills (problem-solving, stress management, and anger/impulse control); substance abuse; and support systems. e rehabilitation therapist is also responsible for providing treatment updates with regard to the patient’s progress toward his treatment goals in his assigned individual/group sessions. ey ensure that psy- chosocial rehabilitation services are provided as prescribed in each individual’s treatment plan. Rehabilitation thera- pists include art therapists, recreation therapists, music therapists, and pet therapists.


e role of the clinical social worker is to involve the patient, his or her family and signi cant others, and the relevant community agencies in both the assessment process and throughout treatment. e clinical social worker conducts a thorough analysis of the person’s past life experiences prior


to hospitalization (including historical information and past community experience), analyzes the material found, and develops a plan for discharge that includes making speci c recommendations to the treatment team regarding relevant discharge-speci c interventions based on level of care required in the community or the next level of care. e clinical social worker brings to the team a distillation of speci c factors that contributed to the person’s hospital- ization including history, past successes and failures, com- munity contacts, strengths, supports, and goals that will lead to a formulation of discharge requirements that will increase the likelihood of the person’s successful return to the community.

e clinical social worker, in conjunction with the psy- chiatrist, will address those factors that will likely foster successful discharge, including the individual’s strengths, preferences, and personal life goals, as well as the individual’s level of psychosocial functioning and failures at lower levels of care. e clinical social worker will identify the skills and supports necessary for the individual to live in the setting into which the individual may be placed, will note progress being made toward discharge and the a ercare plan, and will assess the individual’s needs during transitioning to the next level of care.


e psychologist plays a role in treatment planning and shares an important part of clinical leadership with the attending psychiatrist. General clinical psychologists and other psychologists with speci c subspecialty training or certi cation, such as cognitive and behavioral psychology, neuropsychology, psychoanalytic/psychodynamic psychol- ogy, and geriatric psychology (which is comprised of cross- training in geriatrics, organic/neurological disorders, and cognitive-behavioral psychology), make up the psychology sta of a state hospital. Although the ideal is for each unit to have an assigned psychologist, resource constraints o en make this di cult to achieve. In most instances, the psy- chologist and psychiatrist “split” responsibilities between treatment modalities, such as individual and group psy- chotherapy and pharmacological treatment or physical health work-ups. e psychologist takes responsibility for evaluation and provision of required psychotherapeutic interventions, while the psychiatrist focuses on medication management and, in collaboration with a general medi- cine practitioner, physical health interventions. In situa- tions where there is no psychologist assigned to a unit, the attending psychiatrist should have a low threshold for seek- ing the input of a psychologist to manage the challenging

patients who form the bulk of individuals admitted to state hospitals today.

All newly admitted patients should undergo an initial psychological assessment, which is an evaluation leading to a basic psychological pro le of adaptive, intellectual, or personality functioning and characteristics. e primary responsibility of the psychologist then is to identify indi- viduals whose complex or di cult presentation warrants specialized testing (psychological or neuropsychologi- cal) to better ensure the most comprehensive approach to engaging them in treatment. ese tests also assist in pro- viding treatment in the format that speci cally suits the individual’s particular need or impairment.

A psychological evaluation involves the assessment of those various phenomenological, behavioral, and/or cog- nitive components that underlie one’s emotional states and personality. A neuropsychological evaluation, on the other hand, involves the assessment of a variety of cognitive and behavioral functions, such as intelligence, attention and concentration, problem-solving , reason- ing, conceptualization, planning and organization, men- tal speed and exibility, verbal skills, language, academic skills, perceptual and visuo-spatial skills, new learning and memory, and/or motor skills. Neuropsychological evalu- ation is indicated whenever brain-based impairments and/or de cits in any of the listed functions are suspected. Psychological testing may be utilized alone or in combi- nation with neuropsychological testing in order to bet- ter understand how a ective and personality variables may in uence one’s cognitive skills and functions. Both psychological and neuropsychological evaluations are consultative/assessment procedures. By virtue of the chro- nicity or intractability and the overall di cult nature of the illness presentation of most patients in state hospitals, it is prudent to conduct psychological or neuropsycholog- ical testing on all challenging patients, especially if one has not been done in more than 2 years. e results serve as a useful adjunct in formulating the care of these patients.

Psychologists also conduct specialized assessments and treatment such as positive behavioral support plans (PBSP) or problem sexual behavior evaluation and treatment. e criteria for PBSP include that (1) there is no diagnostic clarity even following psychological and/or neuropsycho- logical evaluations, (2) there is lack of clarity regarding the speci c function of a behavior of concern, (3) there is fail- ure to respond to medication trials, or (4) there is a high intensity and high frequency of severe maladaptive behav- ior such as aggression and self-harm. ese assessments are indicated to provide comprehensive functional analyses of the behavior of concern.


In the absence of a behavioral psychologist on a unit, some hospitals establish a mobile behavioral intervention team (BIT) that can be deployed to requesting units to assist in developing behavioral plans as needed and to train sta in their implementation. e behavioral plans range from basic behavioral management techniques or guide- lines to more comprehensive (and sometimes complex) positive behavior support plans. e BIT then monitors the implementation and e ectiveness of the behavioral plan and makes adjustments as necessary.

e most challenging issue with behavioral plans in state hospitals is the consistent application of the plan by the front-line sta members charged with implementing them. With chronic sta shortages common in state hos- pitals, sta members untrained in applying speci c behav- ioral plans are o en “ oated” or reassigned from other units to provide coverage. Even when there is no “ oat” sta on the unit, the application of the plans o en varies across the three shi s. Usually, the unit sta on rst shi , by virtue of being in direct contact with the professional, clinical sta , will more likely be better at implementing the behavioral plan than will sta on the other two shi s. One way to overcome this problem is to designate several units as specialty behavioral units, such as a social learn- ing program unit or a unit for other forms of behavioral intervention, in which a token economy system and other behavior re-enforcements techniques and shaping groups are at the core of unit’s functioning. Sta will ultimately become steeped in the behavioral techniques by immer- sion and will be, therefore, more likely to consistently apply the interventions. is is useful for a select group of patients identi ed as needing behavior modi cation to manage their aggressive behavior or to improve their social functioning in the community.

Psychologists also take responsibility for psychotherapy programs in state hospitals. It is not infrequent that patients are moved from one unit to another, sometimes several times while in the hospital, but retain the same psychother- apist. Some state hospitals have developed a mobile psy- chotherapy service (or person) to provide psychotherapy across all units of the hospital. In this situation, all referrals for psychotherapy are assigned (to interns or other trainees and to regular sta ) by the psychotherapy service. e psy- chologist in turn supervises the interns and other trainees.

Psychoanalytic, psychodynamic, and personality theory can be useful in the state hospital to understand and man- age individual psychopathology and the milieu. Although all professional sta may draw on this knowledge, o en the psychologist is best prepared to use these approaches. In any event, all professional sta must attend to the problems

posed by having severely ill people living together for pro- longed periods of time in closed environments.


e MHAs (frequently called psychiatric technicians) play an important role in care and treatment planning. Because the MHA spends as much, if not more time with the patient than most other members of the treat- ment team and has the opportunity to observe the patient across the three shi s and in di erent treatment and lei- sure settings, the MHA presents to the team a more com- plete description of the patient’s behavior and response to treatment interventions. Information garnered through regular (weekly) formal meetings between MHAs and patients o en informs treatment, too. e skills of indi- vidual MHAs can be harnessed to engage patients in activities during o -shi s, weekends, and holidays; keep- ing patients busy decreases opportunities for mischief and aggressive behaviors. For example, sports-loving MHAs can be encouraged to run sports groups, watch vari- ous sports with patients, and engage them in discussions about them. Other group activities include games group, cooking group, news group, women’s and men’s groom- ing group, and so on. Some hospitals train MHAs to use simple manuals developed to teach basic social skills to the most regressed patients in small groups. Although these are not psychoeducational groups, they do teach appropriate social skills and nonviolent interactions, and they comple- ment the more structured groups run by psychologists, rehabilitation therapists, and, sometimes, social work- ers. Most importantly, they improve communication and positive interaction between patients and MHAs, foster mutual respect, and ultimately decrease opportunities for aggressive behavior by patients.


Although the patient is not a formal member of the treat- ment team, he or she is not a passive recipient of treatment decisions made by the IDT; in fact, the patient is the most important member of the “treatment team.” Patient advo- cacy groups increasingly assert that treatment decisions be driven by the patient, with professional advice only from clinicians; hence, programs and interventions to encourage patient empowerment are on the rise. Most state hospitals have patient advocates on sta , and some have additional legal advocates, o en imposed on the hospital through legal mandates or consent decrees, whose role is to protect the


civil rights of hospitalized patients. Patients have free and easy access to these advocates and are encouraged to present their grievances to them if they are unable to resolve them with their treatment team. To further foster a collaborative relationship between patients and the state hospital, some hospitals have established patient–sta steering commit- tees with representatives from patients across the hospital, front-line sta members, and some members of the hospital administrative leadership, such as the program manager and the medical director. Patients on the steering committee run the meeting with the support of sta . Because patients are housed in the hospital for months and even decades, the hospital becomes their home by default. Patients are there- fore encouraged to present issues that would improve their comfort in the hospital, including environmental issues (e.g., more water fountains, chairs, dustbins in the court- yard, more lighting and heat, etc.) and household issues such as type of toiletries, clothing, laundry times, frequency of showers, and so on. e steering committee also requests and plans activities for special holidays and events (e.g., July 4th, Christmas, and the Super Bowl). In turn, patients are informed of new interventions and proposed changes in the hospital early enough to allow for their input before the changes or interventions are introduced. In most hospitals, a patient representative is included in the planning of such proposed changes and interventions.

State hospitals also empower patients through their involvement in publishing a newsletter on a regular basis, developing and participating in a patient–sta -run radio station, and including patients in the training of new sta .

Before the advent of the recovery movement, the idea of chronically ill and disabled psychiatric patients being active participants in decision-making regarding their well-being and self-maintenance was not always seen as possible or necessary. Now, however, patients are empowered to view themselves as able and capable of managing various aspects of their lives, and they are encouraged to not be afraid to pursue their desires and goals. To that e ect, the treatment/ recovery planning process is increasingly focused on cre- ating opportunities for patients to manage their lives and on developing resources to enable them to do so. As such, patient-centered care in a state psychiatric hospital must necessarily integrate both treatment and rehabilitation.


e treatment plan is essentially a written contract between a person and his treatment team that maps out the supports

and interventions that the patient will receive to resolve his reasons for admission so that he can be discharged as quickly as possible to a less restrictive setting in the commu- nity.22 e treatment plan describes a complex set of clini- cal interventions designed to address an array of biological, psychological, and social challenges, as well as to provide a conceptual framework for coordinating services.

One of the most salient in uences of the recovery move- ment (see Chapter 3) in inpatient care lies in its in uence on the process of treatment planning. Recovery-oriented treatment planning is a collaborative process, directed by patients (consumers) and produced in partnership with care providers and natural supporters with the goal of encouraging consumer preferences. It aims to identify the speci c steps a person can take, within a speci c time frame, along with the interventions that can be provided to enable and support those steps, for the purpose of improving his or her life and moving it toward the individual’s long-term aspirations.

Recovery-oriented care focuses on goals that are quite di erent from traditional treatment goals. Rather than focusing only on reducing symptom severity, increasing insight, and strengthening adherence, all of which remain important, recovery-oriented care values goals such as man- aging one’s own life, promoting satisfying relationships and spiritual ful llment, facilitating access to educational and occupational outlets, assisting in access to permanent housing, and contributing to other quality-of-life indices that emphasize community integration. As such, treat- ment interventions including social skills training, money management, navigating the challenges of transportation, con ict resolution, vocational skills, and leisure skills that would enhance the chances of success in the community are emphasized in individual and group therapy sessions, irrespective of impairments imposed by the patient’s symp- toms. ese “core groups” are graded so that patients prog- ress from the basic level to a more sophisticated level as they improve.

Personal strengths play a prominent role in recovery- oriented care. ey are deliberately incorporated in the treatment plan. In traditional care, they are acknowl- edged rather than actively used. In recovery-oriented care, strengths and assets are leveraged toward achievement of the individual’s stated goal. Treatment should be tailored to the patients’ strengths and assets to improve the chances of success.

In a traditional, medical model treatment plan, patients’ presenting symptoms are identi ed as problems; a problem list is subsequently generated, and these form the founda- tion of the treatment plan. In contrast, recovery-oriented


care focuses on the patients’ hopes and aspirations and on the barriers (not problems) preventing them from achiev- ing their goals. Hence, the recovery-oriented care is person- centered; it requires that, to the extent possible, the person in treatment identify life goals that set the treatment plan into motion. e focus of treatment planning in this model is not the eradication of problems or symptoms, but rather the mitigation of the barriers that interfere with a person’s quality of life. erefore, unlike in the traditional treatment model, patients with identical diagnoses are likely to have distinctly di erent treatment plans.

Distinguishing barriers from problems has the bene t of acknowledging that symptom elimination is not always possible—and indeed is o en elusive in individuals who are long-term residents of public mental health hospitals. is reconceptualization of problems makes it possible to focus treatment on a wider range of factors that interfere with reaching life goals. Examples of such factors include both de cits, such as limited skills in a given life domain (e.g., social, self-care, safety), paucity of social supports, or hopelessness/helplessness, or excesses, such as interpersonal violence, self-injury, or institutional dependence. From this perspective, treatment aims at ensuring that barriers to life goals are e ectively overcome so that the individual can transition to a less restrictive level of care. e patient’s input must be adequately represented in the treatment plan, and it must be written in language easily understood by the patient and his or her natural support.

e treatment/recovery plan is based on a foundation of partnership, in which there is mutual respect between the patient and the caregiver. e model recognizes that the person seeking care is an autonomous individual who deserves respect and that the ultimate decision-making rests with the autonomous individual. However, the expertise of the caregiver is also recognized, and high regard is given to his or her professional opinion.

It must be acknowledged, however, that for a subset of patients, especially those mandated by the legal system into the hospital, the concept of autonomy as described here may be circumscribed by external factors. ese include indi- viduals involuntarily admitted to the hospital due to risk of danger to self or others, those legally deemed to not have the capacity to give informed consent to treatment, those admitted for restoration to competency, patients found NGRI and whose subsequent treatment and movement are determined by a body or system outside of themselves or their advocates, and those transferred from the Department of Correction (DOC) for psychiatric stabilization a er which they will be returned to DOC custody. For these spe- cial classes of patients, recovery-oriented, patient-centered

care should be pursued with caution. As noted in Chapter 3, a patient-centered plan should allow for uncertainty, set- backs, and disagreements because these are inevitable steps on the path to greater self-determination. Additionally, in their path to recovery, a patient’s “dignity of risks” and “right to fail” should be recognized. Understandably, the auton- omy of a patient who, in response to untreated paranoid psychosis, killed another person, would be restricted. Any setback or uncertainty regarding her recovery would attract much concern, thereby further limiting her autonomy; she would be seen as having lost her “right to fail” because any failure could lead to unacceptable consequences. However, regardless of legal status, all patients should be encouraged to actively participate in the treatment planning process and exercise choices that will impact their treatment and life, even if such choices are from a restricted range of options.


Partial hospitalization is a treatment program for individ- ualswhodonotrequirepsychiatricinpatienthospitaliza- tion but who need an extended period of observation and treatment during the day. If provided in a timely manner, it can avert inpatient hospitalization. Partial hospital- ization also can be used to transition inpatients into the community while still receiving intensive treatment and monitoring.

e rst psychiatric day hospital opened in Moscow, during the 1930s, to be followed a decade later in Montreal and London.23,24 e British Mental Health Act of 1959 encouraged the spread of the modality in England and simi- larly, in the United States, the 1963 Mental Health Centers Act mandated this form of service.25 Two years later, the American Association for Partial Hospitalization became established, forming chapters in most states. Annual meet- ings (with well-prepared proceedings) began in 1976, and 1983 saw the inauguration of the quarterly International Journal of Partial Hospitalization.

Although the use of day hospitals may appear to be wan- ing in state hospitals in the United States,26 a recent report from Scotland has demonstrated their e ectiveness for returning forensic patients from the forensic hospital to the community.27

It remains to be seen whether this trend is a ected by the implementation of the A ordable Healthcare Act of 2010. Although not many mental health professionals have experience with this treatment modality, it has worked well for such challenging groups as individuals with substance use disorders and those living with borderline personality


problems. It is especially relevant as a means of safely reduc- ing length of stay for inpatients.

e use of partial hospitalization for the restoration of competency to stand trial has not been systematically dem- onstrated in the literature so far. It may be of some ethical concern that inpatient hospitalizations for competency res- toration increased by 20% between 1968 and 1978, a decade that saw a 20% decrease in admissions overall. e implica- tion is that, as hospitalization becomes less available, more patients are being treated in departments of correction, more by default than by design, and more for nonwhites than for whites.28 ese numbers at least suggest that little or no use of day hospitals is being made for the treatment of patients found incompetent to stand trial and, moreover, that cor- recting this anomaly may be an e ective way to decrease the tendency to criminalize the mentally impaired.

Partial hospitalization has played some role in the eval- uation and treatment of insanity acquittees. is applica- tion has taken place in Oregon, which for many years has entrusted its insanity acquittees to the jurisdiction of its Psychiatric Security Review Board. An early report pointed to the importance of community programs for successful rehabilitation based on legal, clinical, and nancial results.29 One of the program’s major elements was a large day treat- ment center in a major urban setting, described in a later report.30 e program provides individualized treatment for its long-term mentally ill clients including suitably quali ed insanity acquittees. Between 1980 and 1983, it accepted 110 referrals; most of the rejections were due to the patients’ perceived inadequate interest or motivation. Once having entered treatment, a er an average of 9 months, half of the patients were returned to the state mental hospital unit for more intensive inpatient treatment. e authors noted di – culty in achieving a transition to independent living among the unsuccessful patients. Among the successful individu- als, any new o enses were few and less serious than their original charges.

Other case study or small series reports include the application of partial hospitalization for adolescents in a rural setting,31 mentally disturbed adolescent o enders from the Court Referred Project in Brooklyn,32 and aggres- sive adult psychiatric patients in a rural setting.33


Con icts among the various parts of the complex public system sometimes play out in the clinical care of a patient in the hospital. A range of organizations that include

community agencies that provide outpatient care (be they public, private, or publicly supported), patients rights organizations, state bureaucracies such as the departments that oversee adult and child public mental health services, public mental health services for individuals with develop- mental disorders, regional and federal regulatory agencies (such as the Joint Commission, the Department of Public Health, the Centers for Medicare and Medicaid Services [CMS], and US Department of Justice), professional orga- nizations (such as the American Psychiatric Association and the American Psychological Association), and hospital employee unions, are parts of the system that can in uence care. e state hospital is only one part of a large and com- plex system. It is useful to think of each of these agencies as constituencies that have “needs” that must be taken into account as treatment in the microcosm of the hospital is being planned for an individual. A few examples follow.


Many state mental health departments have only one or two inpatient facilities. Community agencies serving indi- viduals with severe psychiatric disabilities are, by contrast, numerous. Some are freestanding and for-pro t; others are state-supported through various funding mechanisms such as grants. Each has a unique culture, a unique way of doing business, and a unique history. For example, a community agency may have experienced the loss of a patient to suicide soon a er discharge from the hospital. e recollection of this traumatic outcome avors not only the clinical deci- sions made at that agency (e.g., greater focus on suicide risk management) but also the anxieties of agency clini- cians about accepting patients recently discharged from the hospital.

To ensure continuity of care between the inpatient and outpatient settings, it is necessary for inpatient clinicians to be familiar with the culture of the various community agencies to which they discharge their patients. Without such knowledge, mismatches occur. is task of matching the individual with the appropriate community agency has become so complex that it has largely become a full-time job, one o en assigned to a psychiatric social worker on the IDT.


Public psychiatric hospitals are similar to other organi- zations with respect to their relationship with unions. Sometimes, the missions of the two clash. e basic mis- sion of a union is the protection of its members, both with respect to their safety and their rights. e basic


mission of a psychiatric hospital is ensuring the proper care and safety of its patients. At times, good patient care entails placing an employee at some risk for the bene t of a patient. For example, a psychiatric techni- cian may be asked by a supervisor to accompany a patient to a therapeutic activity o the ward, even though the patient recently had an episode of behavioral dyscontrol and therefore poses some risk of harm to that employee. A tension thus exists between ensuring the employee’s safety and ensuring optimal care. In the example just mentioned, the technician may refuse to do so, sensing that his union would support him.

In our experience, negotiating dilemmas of this sort is best addressed in the context of a history of labor– management collaboration. is collaboration is best fostered through regular (perhaps monthly) meetings between the hospital administration sta and the leader- ship of the union to discuss issues with a view of resolving them expeditiously. If the union leadership and its mem- bers are convinced that the hospital leadership and the pro- fessional sta truly care about the union members and their safety and well-being, then it is possible that the patient will be accompanied to the gym, even though he fairly recently threw a chair against the wall, acknowledging that this intervention poses a risk to the accompanying sta .


Public mental health facilities frequently receive visits by unexpected site visitors from the Joint Commission, the state department of public health, the CMS, and the US Department of Justice, among others. ese agencies o en visit in response to a complaint by a patient, a friend or fam- ily member of a patient, or a disgruntled employee.

With the exception of the Joint Commission, inter- actions with regulatory agencies are o en adversarial in nature because their involvement can result in litigation or other untoward consequences, including loss of funding for the state hospital. If litigation ensues, all parties lose.

Again, in our experience, with rare exceptions, con- icts between regulatory bodies and hospitals usually are resolved and o en with bene t for hospital services. e hospital may have to do some things di erently (e.g., use physical restraints less frequently), secure more resources (e.g., hire more nurses), improve the physical plant (e.g., renovate aged wards), or discontinue a practice (e.g., no more two-point ambulatory restraints), among others. In the end, a solution exists that allows both parties to accomplish their mission; namely, for regulatory agen- cies, to regulate, and, for hospitals, to deliver high-quality

patient care. It is worth noting that the oversight provided by these regulatory agencies ultimately leads to improve- ment and more humane care for patients that otherwise would be lacking.

In conclusion, the following principles emerge from this brief overview of the systemic challenges in state psychiatric hospitals:

1. e task of the public mental health professional is the competent and compassionate delivery of treatments that are evidence-based, in a manner that acknowledges the complex nexus of systemic forces that exert either a facilitating or a complicating in uence on patient care.

2. Synergies exist in these systemic con icts that can be used in a bene cial or harmful way. For example, a regulatory agency review that points out a shortage of nurses empowers hospital leadership to secure funding to hire more nurses.

3. Good outcomes are more likely with an approach that is sensitive to all the complexities of the clinical environment. When bad outcomes occur, it would be comforting to know that the hospital acted professionally and took all the steps necessary to avoid them by incorporating the principles described throughout this chapter.

4. Finally, it comes down to relationships among
all the players within and outside the institution.
A professional attitude, respect, sensitivity, humility, validation, positivity, and collaboration are all essential ingredients to navigate successfully the seas of inpatient care.


Hospitals carefully monitor the quality of care via several mechanisms and metrics. Hospitals must comply with the Joint Commission requirements in order to maintain cer- ti cation. e Joint Commission has developed a set of core performance measures for Hospital-Based Inpatient Psychiatric Services (HBIPS), which went into e ect in 2008. In 2012, the CMS later adopted these measures into its Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS). Also, given recent attention paid to iatro- genic errors, hospitals monitor major treatment events and outcomes. A basic concern in acute care, perhaps more than in any other part of practice in public psychiatry, is the use of restraints and seclusion. Quality assurance teams review restraint and seclusion episodes and pursue treatment strat- egies that minimize their use. Furthermore, morbidity and


mortality conferences review all fatal or other high-risk out- comes, which fortunately are rare. Standard metrics (such as readmissions within 30 days of discharge) are a measure of the success of the hospital service. Another largely inde- pendent dimension of outcome is patient satisfaction, as measured in routine surveys. A variety of process measures related to person-centered care also contribute to the over- all picture of quality. Other important metrics include the use and justi cation of polypharmacy, adequate manage- ment of side e ects of psychotropic medications (e.g., met- abolic syndrome and neuromuscular abnormalities), and identi cation and tracking of individuals deemed by the treatment team to be discharge-ready but for whom there are no appropriate placements in the community.


is chapter has reviewed hospital services as a major domain of clinical practice in public psychiatry. A sea change has occurred in the past 50 years as the public sys- tem swung from almost exclusive hospital care to commu- nity care as the basic premise, backed up by specialized, acute, and chronic hospital services. In the hospital setting, a recovery model and practice in IDTs are consistent with other parts of the public system. Excellent communication with all parts of the system enhances hospital care.


1. Foucault M. Madness and Civilization: A History of Insanity in the Age of Reason. London: Tavistock; 1963.

2. Lamb HRL, Weinberger LE. e shi of psychiatric inpatient care from hospitals to jails and prisons. J Am Acad Psychiatry Law. 2005;33:529–534.

3. Novella EJ. Mental health care and the politics of inclusion: a social systems account of psychiatric deinstitutionalization. eor Med Bioeth. 2010;31:411–427.

4. National Mental Health Act of 1946, HR 4512, 79th Cong, 2nd Sess (1946).

5. Mental Health Study Act, HR 3458, 84th Cong, 1st Sess (1955).

6. Mental Retardation Facilities and Community Health Centers
Construction Act, 88–164, 77 Stat 282 (1963).

7. G l o v e r R W, M i l l e r J E , S a d o w s k i S R . P r o c e e d i n g s o n t h e S t a t e B u d g e t C r i s i s
and the Behavioral Health Treatment Gap. Washington, DC: National
Association of State Mental Health Program Directors; 2014.

8. Medicare and Medicaid: Keeping us healthy for 50 years. Available at Accessed on September, 14, 2015.

9. Medicare and Medicaid: Keeping us healthy for 50 years. Available at Accessed on September, 14, 2015.

10. Mental Health Parity and Addiction Equity Act, 2008. Available at Accessed on September
14, 2015.

11.Community Hospitals: Addressing Behavioral Health Care Needs. Available at twfeb2007behavhealth.pdf. Accessed on September 14, 2015.

12. Bringing behavioral health into the care continuum: opportunities to improve quality, costs, and outcomes. Available at http://www. Accessed on September 14, 2015.

13. Hospital Utilization (in non-Federal short-stay beds). Available at Accessed on September 14, 2015.

14.President’s New Freedom Commission Report. Achieving the Promise: Transforming Mental Health Care in America. Rockville, MD: President’s New Freedom Commission on Mental Health; 2003.

15. A ordable Care Act, HR 3590, 111th Congress, 2nd Sess (2010). 16. Salinsky E, Lo is C. Shrinking inpatient psychiatric capacity: cause for celebration or concern? Issue Brief Natl Health Policy Forum.

17. US Department of Health and Human Services, US Public Health

Service. Mental Health: A Report of the Surgeon General. Rockville,

18. Patient and Family Centered Care Innovation Center.

Accessed on September 14, 2015.
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Psychosomatic Medicine practice guidelines for psychiat- ric consultation in the general medical setting. Psychosomatics. 1998;39(4):S8–S30.

21. Vigod SN, Kurdyak PA, Dennis CL, et al. Transitional interven- tions to reduce early psychiatric readmissions in adults: systematic review. Br J Psychiatry. 2013;202(3):187–194. doi:10.1192/bjp. bp.112.115030.

22.Connecticut Valley Hospital. Treatment Planning Manual. Middletown, CT: Author; 2012.

23. Goldman DL, Arvanitakis K. Ewen Cameron’s day hospital and the day hospital movement. Can J Psychiatry. 1981;26:365–368.

24.Editorial. Day hospitals for psychiatric care. Lancet. 1985;2:1106–1107.

25. DiBella GAW, Weitz GW, Poyntner-Berg D, Yurmkark JL. Handbook of Partial Hospitalization. New York: Brunner/Mazel; 1982.

26. Hoge MA, Davidson L, Hill L, Turner VE, Ameli R. e promise of partial hospitalization: a reassessment. Hosp Community Psychiatry. 1992;43:345–354.

27. Alcock D, White T. Study of the clinical and forensic outcome of admission to a forensic psychiatry day hospital at one, two, and three years. J Forensic Psychiatry Psychology. 2009;20:107–129.

28. Arvanites TM. e di erential impact of deinstitutionalization on white and nonwhite defendants found incompetent to stand trial. Bull Am Acad Psychiatry Law. 1989;17:311–320.

29. Rogers JL, Bloom J, Manson SM. Oregon’s new insanity defense system: a review of the rst ve years, 1978–1982. Bull Am Acad Psychiatry Law. 1984;12(4):383–403.

30. Bloom JD, Williams MH, Rogers JL, Barbur P. Evaluation and treatment of insanity acquittees in the community. Bull Am Acad Psychiatry Law. 1986;14:231–244.

31. Gaylor ML. Treating the adolescent o ender in a rural partial hos- pitalization program. In: Proceedings of the Annual Conference on Partial Hospitalization. 1978;3:107–116.

32. Jacobs BJ, Schweitzer R. Conceptualizing structure in a day treat- ment program for delinquent adolescents. Am J Orthopsychiatry. 1979;49:246–251.

33. Straussman J. e aggressive client in day treatment—mad and bad.

Proceedings of the Annual Conference on Partial Hospitalization.





Deborah Fisk, Joanne DeSanto Iennaco, Donna LaPaglia, and Aniyizhai Annamalai


• Clinical care of persons with serious mental illnesses (SMIs) has shi ed from state-funded inpatient psychiatric hospitals to community mental health centers.

• Community mental health centers provide a broad range of clinical and rehabilitative services of varying intensity to people who have SMI and co-occurring disorders.

• e 2010 A ordable Care Act improves the delivery of mental health and substance abuse services, including integrating primary, acute, and behavioral services and creating patient-centered medical homes for people who have chronic diseases.

• Outpatient services in community mental health centers include walk-in services, continuing care treatment, hospital liaison, and specialty teams.

• E ective delivery of outpatient mental health care requires the development of essential core competencies.

• Outpatient mental health treatment services in community mental health centers are delivered by interdisciplinary sta groups, which include psychiatrists, social workers, psychologists, social and vocational rehabilitation workers, peer workers, and case managers.


Ambulatory behavioral health services are mental health and substance use treatment services that are provided for people outside of institutional settings who have disor- ders that range from mild to severe, including those who have comorbid mental health and substance use disorders (SUDs). In a given year, approximately 26% of Americans who are over the age of 18 su er from a diagnosable behav- ioral health disorder. Of these individuals, an estimated 6% have disorders classi ed as severe, which denote substantial disability and include schizophrenia, bipolar disorder, and severe depression.1

When compared to the general population, people who have a psychiatric disorder have higher rates of a co-existing

SUD.2 Studies have found lifetime prevalence rates for SUDs among people with schizophrenia or bipolar disorder of about 50%.3–5 Integrated care—the treatment of the psy- chiatric disorder in tandem with the SUD—is increasingly recognized as being the most e ective treatment option for these individuals.6

Behavioral health services are provided in a wide variety of primary care and specialty care settings and by a range of di erent providers. Individuals who have mild and moder- ate disorders receive mental health care from primary care practitioners and community health clinics. Individuals who have serious mental illnesses (SMI) and co-occurring SUDs largely receive mental health and case management services from public-sector community mental health centers. ese publicly funded mental health agencies are uniquely sta ed and designed to provide a wide range of


intensive clinical and rehabilitative services to people who have SMIs and co-occurring SUDs.


Before the passage of the Community Mental Health Centers Act of 1963, ambulatory mental health care for people with SMIs and co-occurring SUDs was provided in private practice o ces, very small outpatient clinics, and state hospitals. e Community Mental Health Center Act provided $150 million in federal funds to build new community mental health centers. e primary goal of this expansion was to facilitate the transition of people with SMIs and co-occurring SUDs out of state-funded insti- tutions and back into the community where they would receive their mental health care. Advances in Medicare and Medicaid provided federal government nancing for out- patient mental health care, inpatient psychiatric services at general hospitals, and nursing homes. Rather than focus- ing their attention on treating people with SMIs and co- occurring SUDs in hospital settings, state mental health authorities began to design and deliver a range of clinical and rehabilitative services in outpatient settings.

In 1980, President Jimmy Carter established the Mental Health Systems Act, which was designed to increase and strengthen links between local, state, and federal govern- ments to support and develop community mental health services. is pivotal legislation reoriented ambulatory care to include community mental health, case management, and Assertive Community Treatment (ACT) services. One year later, President Ronald Reagan passed the Omnibus Budget Reconciliation Act (OBRA), which rescinded or redesigned all the items passed in the Mental Health Systems Act. By this time, however, many innovative and intensive community-based mental health care programs were already established as an intrinsic part of the range of services o ered by these community mental health agencies.

Mental health outpatient care delivered by federally quali ed health care centers (FQHC) was also expanded under the OBRAs of 1989 and 1990. is legislation provided enhanced Medicare and Medicaid payments to health centers via cost-based reimbursement for services. Although FQHCs receive funds from other sources, fed- eral entitlements provide a solid base of health and mental health funding for these organizations.

e 2010 A ordable Care Act (ACA) expands and improves the quality of outpatient mental health services for the uninsured. First, this landmark health care law requires that all individual market and group plans provide coverage

for mental health and substance abuse services. Second, the coverage that these insurers provide for mental health and substance abuse care must achieve parity with covered ser- vices for medical or surgical care. ird, insurance coverage for behavioral health care is extended to a large group of Americans who are uninsured. Fourth, new funding will support the construction and expansion of services at com- munity health centers, allowing these centers to serve more individuals, o er expanded hours, and hire additional sta . Finally, additional funding is o ered to states that strategi- cally integrate primary, acute, and behavioral services, thus creating patient-centered medical homes for people who have chronic diseases.

Despite the passage and implementation of federal mental health parity legislation in 2008 and the provisions for behavioral health in the ACA, challenges remain in developing services that are responsive to the comprehen- sive needs of people with serious mental health di culties and co-occurring SUDs. ese challenges include timely access to services and referrals, appropriate organization and coordination of services, and a commitment to provide high-quality evidence-based treatment.


Originally funded in 1963, community mental health cen- ters were designed to account for a changing locus of care in mental health services. Advances in psychopharmacology enabled many people with psychiatric disorders to live self- su ciently outside of institutions and in community settings. As these individuals were moved out of institutional settings, their psychiatric care was shi ed to these newly constructed community mental health centers. Strategically located in high-poverty areas, community mental health centers pro- vided a range of outpatient, partial hospital, and emergency services to residents of de ned geographical areas, known as catchment areas. e legislation also de ned a role for state mental health authorities in planning and coordinating mental health funding and developing and implementing a wide range of housing, social, and vocational support ser- vices for those with SMIs and co-occurring SUDs.

As these agencies grew in size and complexity around the mid-1980s, they faced challenges in engaging, retaining, and e ectively serving people with SMIs and co-occurring SUDs. First, many people who needed psychiatric treatment services had trouble navigating large bureaucratic agencies and did not always follow traditional treatment recommen- dations. Second, many people with SMIs and co-occurring


SUDs have impairments across multiple domains and, as such, need intensive assistance (information, transporta- tion, and brokering) to obtain the community services they require (entitlements, housing, and medical care). ird, the agencies that o ered necessary services were o en them- selves too complex to navigate e ectively. is led to a need for case managers to help people with SMIs and co-occur- ring SUDs obtain the full range of services they needed and support their engagement in ongoing mental health care.

e broad and complex needs of persons with mental ill- ness require that community-based mental health agencies develop collaborative relationships across multiple service sectors, including both within and outside the health care system (income supports, education, employment, housing, police departments, probation and parole o ces, correc- tional system, primary care centers, and general hospitals). Managing a serious illness in which people have myriad social, housing, and vocational impairments requires case management services that are individualized and exibly deployed.

e specialized outpatient and case management ser- vices that are provided to people with people with SMIs and co-occurring SUDs are broader in scope than the care provided through other mental health agencies. Given this, the population of individuals served by community mental health centers is relatively small and the services re ect the type of intensive care required by those individuals.


Compared to community mental health centers, FQHC serve a larger group of persons with SMIs and co-occurring SUDs; however, the focus of care is routine and preventa- tive. e majority of people with mild or moderate psychi- atric conditions such as mood and anxiety disorders and SUDs receive their outpatient mental health care in private doctor’s o ces or FQHCs.7

FQHCs are community-based public and private non- pro t health care organizations that provide a range of pri- mary and preventative care, including health and behavioral health care services. Care is provided regardless of age or income. ese agencies must meet certain criteria under the Medicare and Medicaid programs and receive funds for cer- tain health care initiatives under the Public Health Service Act. ese initiatives include:

• Community Health Centers, serving federally de ned underserved populations.

• Migrant Health Centers, providing preventative medical services to migrant and seasonal workers.

• Health Care for the Homeless Programs, o ering outreach, medical, and substance abuse treatment to homeless individuals and families.

• Public Housing Primary Care Programs providing services to residents of public housing buildings in or near their communities.

Primary care providers in FQHCs receive consulta- tion from behavioral health providers related to the men- tal health needs of individuals presenting for care and o er assistance with assessment and screening, psychopharmaco- logic management, and, when needed, referral to behavioral health services providers in the community.

Some FQHCs o er full-service mental health clinics. ese clinics can accept internal referrals from the primary care providers of people with comorbid psychiatric needs who require more complex management than the primary care setting is able to manage. For example, common refer- rals might include individuals who do not improve a er psychopharmacologic treatment is initiated or who had unexpected responses to treatment. Additionally, behav- ioral health clinicians in FQHCs o er substance abuse screening and treatment, as well as individual, group, and family psychotherapy.

There are benefits to providing both primary care and behavioral health services in one FQHC setting. First, the medical and psychiatric providers are able to more freely exchange information about persons with SMIs and co-occurring SUDs. Second, consultation may be initiated by the psychiatric provider for medi- cal staff to address chronic health conditions, lab work, and other procedures. These advantages are most evi- dent in serving particular subgroups such as individuals being treated for chronic pain and those who have mul- tiple medical problems as well as comorbid psychiatric symptoms (which may include anxiety and depression). The ability to freely communicate and coordinate care between medical and psychiatric providers enhances the quality of both services.

Depending on the size of the mental health unit of the FQHC, services available can be similar to those o ered in community mental health clinics. Smaller FQHCs may be limited in the scope of a er-hour psychiatric care. ese behavioral health programs may have a er-hour coverage, but it is o en limited to medical care. is limits the kind of psychiatric emergency support that is available to per- sons with SMIs and co-occurring SUDs. In turn, FQHCs


may not be able to accept and/or treat individuals who are unable to consistently attend clinic appointments and who have complex comorbidities. ese individuals would be referred for more comprehensive and intensive services at local community-based mental health agencies.


People who have serious behavioral health and substance use disorders o en have co-existing chronic medical condi- tions that lead to increased mortality when compared to the general population.8 ese comorbid medical problems are o en due to side e ects of psychiatric medications, inad- equate diet, a sedentary lifestyle, or some combination of these. ese individuals o en do not receive the medical services they need in a timely manner. ey either do not seek preventative medical care or have challenges navigat- ing the complex medical care service system. Additionally, there is a lack of bridged care across the behavioral health and health care sectors. Recognition of this fact has led to a shi toward integrating primary care services into the mental health sector. As a result, multiple integrated care models are being developed. (Refer to Chapter 5 for more information on these models, such as on-site health care and illness prevention services.)



An integral part of any continuum of mental health care is the provision of walk-in services. is is when behavioral health sta members assess and develop service plans for individuals who are referred or present to the agency. ese encounters are either crisis-oriented or routine. Crisis ser- vices are designed to help individuals manage acute symp- toms of emotional distress. is care is designed for those


• Conduct a complete evaluation including a mental status examination.

• Develop a clinical formulation.

• Develop an initial treatment plan.

• Assess for capacity for self-harm.

having di culty coping with a current life event or stressor. People are more amenable to support and intervention dur- ing times of crisis, thus making it crucial that crisis interven- tion services are easily accessible.

When individuals present in a crisis situation, the cli- nician should focus on understanding the current present- ing problem rather than on obtaining a comprehensive and detailed life history. Clinical sessions are focused on help- ing persons with SMIs and co-occurring SUDs understand the current stressor that prompted them to seek support. Crisis services are brief and problem-focused. If the individ- ual presents with symptoms and is unable to clearly de ne a problem, the clinician can explore his or her current life circumstances (personal, family, work, and social) to help the individual identify the key issue(s). Crisis intervention is a critical service that demands a high level of clinical skill. In order to fully understand an acute situation, the worker needs to access the person’s present behavior and social stressors, but also understand how the person functions when he or she is not in crisis.

Walk-in services also accommodate individuals who are either referred to or present to the agency for routine mental health treatment. ese cases involve an intake and assessment in which comprehensive information about the person is collected and evaluated including:

• Demographic data, which includes age, sex, marital status, veteran status, education, and occupation

• Chief complaint, o en in the person’s own words

• Present episode of illness, including current stressors

• Psychiatric history

• Past and current substance use

• Current medical history

• Personal and social history

• Family history

• oughts about suicide, including details about past attempts

• Aggressive thoughts, including details about past incidents

• Present and past legal involvement

• Trauma history

• Adequacy of environmental resources ( nances, food, clothing, and shelter)

• Protective factors, including personal coping strategies



roughout the initial interview, the clinician is con- ducting a mental status examination and observing the following :

• Appearance, behavior, and speech

• Consciousness

• Psychomotor functions

• A ect and mood

• ought content

• Cognitive functions (orientation, memory, intelligence, and executive functions)

• Insight and judgment
e clinician prepares a written case formulation, which is a summary of key psychological, social, and medical fac- tors and their contribution to the person’s current psychi- atric presentation. e case formulation o en includes di erential diagnoses. Of critical importance is the devel- opment of an initial treatment plan, which includes the length of recommended treatment, frequency of visits, and the provider.
Walk-in units serve as an access point to continuing mental health care both at the agency and in the catch- ment area. A comprehensive and e cient evaluation may be needed before individuals can be referred to agencies in the community for their ongoing mental health care. While serving as a gateway to continuing treatment within its own walls, the public mental health center also serves as a clear- inghouse for information about community agencies that provide continuing mental health treatment services and how to access them.
Many walk-in services also operate mobile crisis teams, telephone crisis services, and actively liaison with local police departments. Mobile crisis teams provide community- based assessments of individuals who are experiencing acute symptoms of mental illness or emotional distress who are unwilling or unable to come to the agency for an evalua- tion. Mobile crisis sta members also provide immediate response to situations in the community in which there is the potential for self-harm or aggressive behavior directed at others. Mobile crisis services are provided to individuals who are not engaged in ongoing mental health care with the agency, as well to those enrolled persons with SMIs and co- occurring SUDs. Generally, mobile crisis units work in col- laboration with o cers from the local police department.
Critical competencies for walk-in clinicians include the ability to engage and develop rapport, to convey a

nonjudgmental attitude, to listen, to convey genuine empa- thy, and the ability to build an alliance and form a trust- ing relationship. Other important competencies include the ability to conduct a mental status examination, develop a clinical formulation, and form an initial diagnostic impression.


In community mental health centers, continuing care treat- ment teams deliver ongoing mental health and case man- agement services to people with SMIs and co-occurring SUDs. It is essential that these services are evidence-based, person-centered, and recovery-oriented.

In its 2001 report, Crossing the Quality Chasm, the Institute of Medicine (IOM) de ned evidence-based prac- tice as the integration of the best clinical research, patient values, and clinical expertise. e best clinical research is determined by systematic reviews that synthesize the results of multiple studies or individualized controlled trials. Patient values refer to the individualized concerns, pref- erences, and expectations that individuals have for their treatment. ese values are essential in guiding all clinical decisions.9 Clinical expertise refers to the pro ciency and judgment that comes from clinical experience and clinical practice (Table 12.2).

In continuing care treatment teams, the primary inter- ventions include medication management and psychosocial treatments. Medication management is an important com- ponent of care for those who have serious and persistent psychiatric and substance use disorders. Many psychiatric disorders necessitate the use of medications for acute symp- tom control, stabilization, and relapse prevention. us persons with SMIs and co-occurring SUDs o en require psychotropic medications for extended periods of time. Additionally, there are subgroups of persons with SMIs and co-occurring SUDs for whom medications are not e ective in reducing or stabilizing psychiatric symptoms. For example, it is estimated that 25–50% of people who


• Ability to work as a member of a multidisciplinary team

• Knowledge of evidence-based treatment models

• Ability to provide individualized, person-centered, and recovery-oriented care



have schizophrenia have persistent residual symptoms,10– 12 even when they do adhere to a prescribed medication regimen. Clozapine, an antipsychotic medication with superior e cacy in treating refractory symptoms of schizo- phrenia, is limited in that only 30% of persons with SMIs and co-occurring SUDs show an adequate response to the medication.13,14

Many other biologic treatments, some of which are still under development, are also used with treatment-refractory persons with SMIs and co-occurring SUDs, especially those with mood disorders. Electroconvulsive therapy, one of the oldest somatic treatments, can be e ective for the afore- mentioned individuals who have major depressive disorders or for acute symptom control in many psychiatric condi- tions.15 Examples of other somatic treatments include vagal nerve stimulation and transcranial magnetic stimulation for refractory depression and other mood disorders.16 However, symptom reduction with medications or other biologic treatments is only part of the overall self-management plan. A collaborative discussion of the person’s goals, treat- ment targets, and barriers to self-management is necessary for e ective care. Pharmacologic treatment, in particular, should always be within a person-centered context. Shared decision-making about use of psychiatric medications— patient-centered medicine—is being advocated as an ethical imperative17 that also has been shown to increase medica- tion adherence and improve outcomes.18

An important aspect of patient- or person-centered medicine is an understanding of the risks and bene ts associated with the use of medications. It is important that persons with SMIs and co-occurring SUDs understand the risks and bene ts associated with prescribed medications so that they can make an informed choice about whether or not to take these medications, as well as to participate in e ective monitoring to minimize side e ects and thereby improve long-term outcomes. Many second-generation antipsychotics are associated with weight gain and meta- bolic disturbances and require persons with SMIs and co- occurring SUDs to appropriately manage these conditions with the support of outpatient behavioral health clinicians. Also, adherence to treatment is improved if speci c treat- ment targets are identi ed by individuals rather than prede- termined by clinicians. Also, somatic-based treatments are more likely to be e ective if based within a person-centered, recovery-oriented model of care.

Shared decision-making can be di cult to implement in circumstances in which the individual’s judgment is impaired due to symptoms of mental illness. Also, stigma surrounding mental illness is an important reason why peo- ple are resistant to acknowledging and accepting treatment.

ere are also situations in which treatment is involuntary, such as when a physician commits someone to a hospital. In these circumstances, it is still possible to nd commonly agreed upon goals between the provider and the patient. In cases where coercion is required, such as in forensic and acute care settings, these coercive measures should be undertaken in ways that the person’s remaining degree of autonomy is maintained. e ultimate goal is always recov- ery and self-management. e following principles are help- ful in attaining goals of self-management:

• Elicit the person and family’s perspectives on the issues that brought the person to care.

• Assess the person and family’s perceived needs and priorities, including cultural preferences (e.g., ethnic, sexual, spiritual).

• Identify the person’s short- and long-term goals.

• Identify medication targets that indicate that people are overcoming barriers to life goals or increasing their quality of life (over and above symptom reduction).

• Prescribe medication as one component of an overall self-management plan that builds on the person’s and his or her family’s strengths.

• Identify and address barriers to self-management, including the need for additional supports
(e.g., transportation, child care, reminders, environmental modi cations).19
Empirical evidence exists for the use of several psycho- social treatment interventions for people who have schizo- phrenia. ese include intensive case management, assertive community treatment, family psychoeducation, and sup- ported employment services. ese psychosocial interven- tions, evaluated in randomized clinical trials, have been found to be e ective in various ways for those with schizophrenia:
• Intensive case management is associated with reduced use of psychiatric hospital services, higher rates of employment, lower rates of homelessness, and overall improvements in general functioning.20
• Assertive community treatment is associated with reduced use of psychiatric hospital services and higher rates of maintaining involvement with outpatient mental health care.21
• Family interventions, including those that educate families about schizophrenia, and provide family support, o er families training in e ective


problem-solving and communication and are associated with fewer rates of relapse.22

• Supported employment services are associated with improved vocational outcomes.23,24

Empirical evidence has also found that cognitive behav- ior therapy is an e ective treatment for people who have anxiety disorders25 and for those who are severely depressed, provided that it is conducted by well-trained therapists.26 Additionally, there is empirical evidence that dialectical behavior therapy is an e ective treatment for people with borderline personality disorder,27 and motivational inter- viewing is an e ective treatment for people who have alco- hol or drug use disorders.28

Many states, including Connecticut, have implemented the evidence-based practice of integrated dual disorders treatment (IDDT). is allows for the provision of treat- ment for both illnesses within one program conducted by a multidisciplinary team. Integrated treatments, in addition to ensuring that both mental health and substance abuse issues are addressed in one setting, also allow for compre- hensive person-centered recovery planning. is is optimal because it avoids placing the burden on persons with SMIs and co-occurring SUDs who formerly had to seek services from two separate systems of care (the public mental health system and the specialty substance abuse treatment system). Drake and colleagues have found that the three most e ec- tive psychosocial interventions for improving substance use outcomes in integrated service systems are group counsel- ing, contingency management, and longer term residential services.29

It is important that clinicians receive education and training in psychosocial treatment approaches that meet best practice standards, including the therapeutic tech- niques used in these approaches. Clinical supervision from more experienced sta members is also an essential tool in supporting and monitoring clinicians as they implement these techniques in practice.

To complement the range of evidence-based psychoso- cial treatments, supportive individual counseling, medica- tion management, group treatment, resocialization groups, and other specialized groups (clozapine, relapse prevention, trauma groups) can be o ered. Since serious psychiatric dis- orders can have a substantial impact on activities of daily living, case management, social rehabilitation, and voca- tional rehabilitation services are important additional com- ponents to outpatient behavioral health treatment for many individuals. ese support services are designed to assist people with serious behavioral health disorders develop basic skills in various activities of daily living. Some of

these skill areas are in money and medication management, as well as in health and wellness, social and interpersonal skills, vocational assistance, and entitlement and housing supports.

e care of many persons with SMIs and co-occurring SUDs by behavioral health treatment teams requires con- tact with a range of agencies and providers outside of the mental health service system. is includes a range of hous- ing supports including local housing authorities, board- and-care facilities, homeless shelters, and local landlords. Additionally, entitlement workers, probation and parole workers, visiting nurses, social and vocational workers, and health care personnel are also involved in the care of people who have SMIs and co-occurring SUDs (see Box 12.1).

Continuing mental health treatment teams in commu- nity mental health centers are o en interdisciplinary and include psychiatrists, social workers, psychologists, social and vocational rehabilitation workers, peer workers, and case managers. ese teams are responsible for providing a broad range of treatment services including pharmaco- therapy, individual, group and family psychotherapy, brief treatment, crisis management, case management, social and vocational rehabilitative services, housing supports, and psychoeducation. Guided by recovery-oriented principles, individual and group treatments are person-centered. ey are designed for persons with SMIs and co-occurring SUDs based on their clinical and current psychosocial situations as well as their individual preferences.


Mr. W. is a 48-year-old man who has a long history of schizo- phrenia. He has resided in mental health-supported housing for two decades. Despite taking psychiatric medication, he continues to have paranoid delusions. A er a bout of enuresis, he allowed the case management sta of the housing program to take him to a medical doctor where he was found to have a small mass on one of his kidneys. He refused to consider the doctor’s recommendation to have it removed because he believed that his internal organs were not his and that God told him that he did not need surgery. An additional case manager was assigned to coordinate care with all involved providers. His clinician worked with the psychiatrist to apply for conservatorship, which was awarded to the person’s sister. A er having been estranged from the family for some time, his sister worked with the providers and convinced Mr. W to have what was a successful surgical procedure.



Essential competencies for continuing treatment team clinicians include the ability to work as a member of an interdisciplinary team, knowledge of evidence-based treat- ment models, the ability to exibly provide case manage- ment services or collaborate with case managers, and the ability to provide individualized, person-centered, and recovery-oriented care.


Deinstitutionalization refers to an international reorienta- tion in the provision of treatment for peoples with SMIs and co-occurring SUDs in which the psychiatric treatment provided to these individuals was shi ed from state hospi- tals to community settings. is involved three interrelated and evolving forces. e rst is the release of long-term hospitalized persons with SMIs and co-occurring SUDs from institutions into the community. e second is the diversion of new hospital admissions and readmissions, and the third is the development of a wide array of community mental health treatment and residential care services.

Prior to the mid-1950s, people with SMIs and co- occurring SUDs were predominately treated in public men- tal hospitals. In 1955, the number of individuals in these hospitals peaked with a total of 558,922 people in state facil- ities. Between 1955 and 1965, there was a 15% reduction in these hospitals, and, a er the passage of Medicare in 1965, these rates dropped a dramatic 65%. By 1980, the total num- ber of public state hospital residents declined to 137,810.

is historical shi in care is the result of a complex set of interrelated factors, was led by the introduction of Medicaid, which paid for nursing home care for people with SMI. As a result, many individuals were directly transferred from state hospitals to nursing homes, and, through screening processes, many more prospective state hospital residents with SMIs and co-occurring SUDs were diverted to nursing care facili- ties, thus shi ing the cost of psychiatric care for these indi- viduals from the states to the federal government.30

Deinstitutionalization was further fueled by the discov- ery of antipsychotic medications, lobbying by families and human rights groups, the expansion of federal disability income, and federal reimbursement for inpatient psychiat- ric services at general and private hospitals.

e implication of deinstitutionalization for psychiatry is that access to psychiatric inpatient beds is more restricted, hospital admissions are of a relatively short duration, and inpatient hospital psychiatric beds are located across dif- ferent agencies (i.e., general hospitals, private psychiatric

hospitals, and state hospitals). Despite the restricted access to acute psychiatric beds, inpatient psychiatric care remains an essential and important component of the mental health service system. Inpatient psychiatric treatment is used for acute stabilization of psychiatric symptoms. Examples of people who are admitted to inpatient psychiatric beds include individuals who are experiencing severe psychiat- ric symptoms and have di culties with behavioral control, are at serious risk for self-harm, pose serious physical risk to others, or have complex comorbid medical and psychiatric problems or neuropsychiatric impairment.

Local emergency rooms serve as the main portal of entry to inpatient psychiatric beds in speci ed geographic areas. is makes it important that community mental health agencies develop and maintain a close working alli- ance with their local emergency departments, thus a ord- ing e cient sharing of the clinical information necessary for a thorough evaluation of persons with SMIs and co- occurring SUDs. is is particularly important for making the important decision as to whether or not to hospitalize a particular individual. is cross-agency collaboration helps optimize the use of available psychiatric inpatient beds, the majority of which are now located in local general hospitals (see Box 12.2).

An important strategy for monitoring and supporting peoples who are transitioning out of hospitals to outpatient behavioral health care involves establishing a liaison role. A liaison can provide an important bridge for people to


Mr. L. is a 39-year-old man who has a long history of schizo- phrenia and persistent delusions that he has had children with several women who have kidnaped them. He insisted that a woman who worked at a local public elementary school was the woman who kidnapped one of his daughters. He started stalking her, calling the school and telling them to re her because she was a danger to children, and visiting the school playground during school hours looking at the children and hoping to nd his daughter. He was involuntarily hospitalized on the psychiatric unit of the local general hospital. ree days later, one of the covering social workers called the agen- cy’s hospital liaison to say that they planned to discharge the patient because he had baseline psychotic symptoms. e liai- son reminded the sta of the circumstances that preceded the admission. e social worker conveyed this information to the hospital treatment team who decided to hold the patient for a longer admission and invited the outpatient clinician to the hospital to assess the patient further



• Facilitation and collaboration skills

• Willingness to participate in shared planning and decision-making

• Demonstration of mutual respect and con ict resolution skills

• Knowledge of both private and public psychiatric systems, including emergency rooms and inpatient units
the community, whether they are leaving general hospital psychiatric units a er short-term admissions or state hos- pitals a er longer term admissions. e liaison can estab- lish a relationship with the individual’s treatment team, thus facilitating communication between the inpatient and outpatient teams. Additionally, the liaison can visit the person in the hospital, help create an individualized transi- tion plan, link these individuals to community services, and schedule a er-care appointments for mental health care prior to their discharge from the hospital. A successful tran- sition from inpatient to outpatient treatment may involve reinstatement of entitlements, securing housing, a referral to social rehabilitation services, and helping to ensure fam- ily support.
e liaison can arrange for newly assigned outpatient clinicians to meet individuals before they leave the hospi- tal. Rates of follow-up a er discharge have been enhanced by direct communication between individuals and newly assigned clinicians.31,32
Essential competencies for liaison sta include knowl- edge of both private and public psychiatric systems includ- ing emergency rooms and inpatient units and facilities, facilitation and collaboration skills, willingness to partici- pate in shared planning and decision-making, the ability to cooperate and work together, demonstration of mutual respect, and con ict resolution skills.
Several intensive and innovative programs exist in the mental health sector including ACT teams, jail diversion programs, crisis intervention teams (CITs), and homeless outreach teams, among others. Each of these programs or teams provides speci c services to a particular subgroup of people with SMIs and co-occurring SUDs. ese programs are o ered as part of a continuum of care, with people ex- ibly moving between outpatient behavioral health services and specialized care teams.


• Flexibility • Persistence

• Ability to work on interagency and interdisciplinary teams

ACT is an evidence-based treatment model that pro- vides assertive and community-based clinical and case man- agement services to individuals who have serious behavioral health disorders and co-occurring SUDs who have not oth- erwise engaged in outpatient treatment. Interdisciplinary teams provide psychiatric care and case management ser- vices to these individuals in community settings, including their own living environments. ACT teams maintain a low client-to-sta ratio and provide services beyond the typi- cal workday. ese services are reserved for people who are severely ill and who use intensive services such as inpatient and emergency psychiatric care.33 Given the volume of the services provided by ACT teams, there are o en waitlists for this e ective service, and, in some agencies, the service is not available. In these circumstances, severely ill individuals receive outpatient treatment services (see Chapter 13 for a more detailed summary of the ACT team model).

In many community mental health clinics, forensic ser- vices have been designed in response to concern about the high prevalence of people with mental illness in criminal justice and correctional settings. It is estimated that people with SMI comprise between 6% and 18% of the inmates in jails and prisons across the United States, a rate that is two to ve times higher than that of the general popula- tion.34 Rates of arrest among people with SMI are also high: between 28% and 52% of persons with SMI in the United States have been arrested at least once.35–37

Jail diversion programs target people with SMIs and co- occurring SUDs who have committed nonviolent crimes or probation o enses. is is bene cial in diverting such individuals from jail to community mental health pro- grams. ese programs screen individuals for the presence of a mental illness and evaluate them or collaborate with mental health professionals who conduct these evaluations. Furthermore, diversion programs seek to negotiate with attorneys and the courts for a disposition that links these individuals with psychiatric and substance abuse treatment rather than continued con nement, an important com- ponent of follow-up procedures. ere is recent evidence that jail diversion programs lead to reduced days spent in jail and increased connections to community-based ser- vices for those who have SMIs and co-occurring SUDs.38



Pinals (2014) suggests that expanding community-based psychiatric and case management services for people with SMIs and co-occurring SUDs in all phases of criminal jus- tice involvement is important in helping these individuals remain connected with psychiatric care and providing assis- tance in securing tangible supports, including entitlement and housing services39 (See Chapter 8 for a more detailed discussion of forensic services for people with SMIs and co-occurring SUDs.)

A CIT is a collaborative model between mental health sta and local police. A CIT is designed to enhance the abil- ity of police o cers to respond to situations in the commu- nity that involve people with SMIs and co-occurring SUDs. Although the goals of these programs vary from one site to the next, overarching goals include providing improved safety for o cers and the disordered individual, linking individuals to psychiatric services, and diverting those with SMIs and co-occurring SUDs to hospital settings rather than jails. Research on CIT has found that it improves o cers’ con dence in interacting with citizens with men- tal illness,40–42 enhances their knowledge about mental illness,41,42 improves the ability to divert those with SMIs and co-occurring SUDs from arrests, and improves rates of referrals to psychiatric clinics for follow-up services.43

Homeless outreach teams (refer to Chapter 13 for more detail on this model) are designed to locate people with mental illnesses or co-occurring disorders who are not receiving behavioral or medical health care and provide intensive case management to link them with mental health resources, substance abuse treatment, medical services, and housing. Developing collaborative relationships with a con- tinuum of community providers, particularly public hous- ing agencies designed to extend subsidized housing services for people with serious behavioral health disorders, is par- ticularly important in the e ective delivery of homeless services (refer to Chapter 13 for more detail on homeless outreach team models).

Competencies that are essential for sta members who work in these specialty teams will vary based on the speci c team, but o en include persistence, the ability to broker services between agencies or service systems, and the ability to work on interagency and interdisciplinary teams.


e outpatient behavioral health workforce is large and interdisciplinary. e adoption of core competencies neces- sary for outpatient sta supporting patients with psychiatric

disorders is complex, dynamic, and ongoing. Competence in outpatient behavioral health care has been de ned as “attitudes, values, knowledge, and skills needed to deliver quality services to people with SMI”.44 A competency is a measurable human capability required for e ective delivery of evidence-based and recovery-oriented outpatient care in public-sector psychiatry.

In 1998, the Substance Abuse and Mental Health Services Administration (SAMHSA) commissioned a con- sensus group that articulated 12 general core competencies for providing outpatient services to adults with behavioral health disorders. ese include the knowledge and skills necessary to (1) develop a person-oriented service delivery system; (2) engage and provide relevant services to those close to the patient (i.e., family and friends); (3) develop psy- chosocial knowledge about SMI; (4) develop basic biologi- cal and pharmacological knowledge about mental illness and psychiatric medications; (5) develop and implement a range of e ective psychosocial interventions; (6) provide individu- alized treatment approaches, including the ability to design, deliver, and document their interventions; (7) maintain a thorough understanding of community resources, entitle- ments, and bene t programs in order to assist persons with SMIs and co-occurring SUDs in obtaining them; (8) under- stand relevant laws and legal issues; (9) demonstrate the ability to collaborate within and across multiple funding, governing, and service agencies; (10) ensure that agency providers adhere to professional and ethical standards and pursue professional development; (11) understand the ele- ments of culturally competent mental health treatment; and (12) be aware of the importance of research and other types of feedback to improve personal and agency outcomes.44

In 1999, the Surgeon General’s Report on Mental Health rst introduced the concept of recovery. e SAMHSA’s working de nition of recovery is a process of change through which individuals improve their health and wellness, live self-directed lives, and strive to reach their full potential.45 Some key components of recovery include involvement in ful lling activities and having a sense of pur- pose in one’s life, as well as hope, dignity, respect, choice, and social support. Recovery-oriented care is a collab- orative model that identi es and incorporates a person’s goals, interests, and strengths in order to support him or her in living a full and meaningful life in the community. Additionally, it promotes person-centered care or shared decision-making in which the provider includes the person in any and all aspects of his or her treatment.

All aspects of clinical outpatient services, including medication management, psychosocial interventions, walk- in and crisis services, liaison to inpatient hospital units, and


specialty services, require competencies that are evidence- based and recovery-oriented. Ongoing training and super- vision are essential tools for sustaining these essential competencies.


Community mental health centers provide person-centered and recovery-oriented clinical and rehabilitative services to persons with SMIs and co-occurring SUDs. ese specialty care services are provided to a relatively small group of eligi- ble individuals who have a range of needs, at times intensive in nature. Interdisciplinary teams provide outpatient behav- ioral health care services that include walk-in and crisis ser- vices, continuing care treatment, hospital liaison services, and specialty teams. Evidence-based medication manage- ment and psychosocial treatments are o ered in tandem with case management and rehabilitative services. Designed to provide a range of supports, these services help individu- als to lead independent and full lives in the community. Particular emphasis is placed on the sta member’s ability to see the person beyond his or her illness and believe in his or her potential for recovery.


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Anne Klee, Lynette Adams, Neil Beesley, Deborah Fisk, Marcia G. Hunt, Monica Kalacznik, Howard Steinberg, and Laurie Harkness


When working with special populations, practitioners must:

• Understand the culture and speci c needs of each special population.

• Identify and understand the barriers to care that the population may experience.

• Be aware of one’s own biases and develop one’s multicultural competence through continuing education, consultation, and personal re ection.

• Work within interdisciplinary care teams to engage these individuals in welcoming and recovery-oriented care.

Hospitals and clinics provide acute and traditional out- patient treatment, but many special populations require enhanced services in the home, on the streets, or in other settings like transitional living facilities. Providing community-based mental health, psychotherapy, case man- agement, and psychosocial rehabilitation services requires a unique set of skills. When working with special popula- tions in the community, it takes a seasoned practitioner with sophisticated clinical knowledge and skills to apply his or her expertise and provide comprehensive quality mental health care. When a practitioner goes into the community, boundaries and the locus of control change, and o en the predictability of how the encounter will unfold varies. e practitioner must attend to environmental and behavioral cues and then creatively, comfortably, and seamlessly pro- vide quality care. e ability to readily assess physical safety by examining the environment is paramount to the success of a community-based intervention for both the client and the practitioner. Utilizing an interdisciplinary team (IDT) approach is critical to this work. Each discipline brings its

unique training and education, but also a di erent set of skills, treatment interventions, and perspectives. In a non- structured setting, successful community-based practitio- ners possess solid clinical skills, self awareness, the ability to utilize a team approach, and know when to call for sup- port or even the police or emergency services. In this chap- ter, we review the important clinical skills and technical knowledge that a practitioner must possess to be e ective in working with special populations and in community set- tings. ese special populations include people with serious mental illness (SMI), homelessness, and traumatic brain injuries (TBI) who o en require residential and/or com- munity wrap-around services to live outside of a hospital setting. is chapter also focuses on the impact that culture and life experiences have on mental health, with a speci c focus on special populations such as veterans, older adults, and lesbian, gay, bisexual, and transgender (LGBT) indi- viduals. Understanding the diverse experiences and person- centered needs of these populations is critical in providing e ective quality care.



Homelessness is a persistent economic and social prob- lem in the United States, although accurate estimates of the population are di cult to produce. Every 2 years on a single night in January, the Department of Housing and Urban Development (HUD) collects point-in-time (PIT) counts of homeless people in communities in every state; participation in the PIT count is a requisite for qualifying for federal homeless assistance dollars (see Box 13.1). e January 2013 PIT count determined that 610,042 peo- ple were experiencing homelessness in the United States. On that night, 394,698 (65%) were staying in emergency shelters or transitional housing programs, and 215,344 (35%) were in unsheltered locations (e.g., vehicles, the street, parks, sidewalks, bus stops or stations, abandoned buildings, and tents). Approximately, 36% (222,197) were people in families, and 387,845 (64%) were individuals.1 One-night and one-week surveys miss individuals who are intermittently homeless or those who are homeless for short periods of time. ey also do not count individuals or families living in motels or those doubled up with family or friends. Homeless individuals who are not living in shelters or transitional housing programs are o en di cult to nd and, even when located, may refuse to disclose that they are homeless.

Whereas veterans comprise approximately 9.5% of the US population over the age of 18,1,2 in January 2013 about 12% of homeless adults were veterans, a percentage that has declined by 24% since 2009.3 In 2014, there was a further drop in the number of homeless veterans in the United States by 33% since 2010. Most homeless veterans are 55 years or older, but a growing proportion are younger ser- vice members who served in Iraq and Afghanistan, includ- ing women and families. Although homeless veterans are more likely to be older than the general homeless popula- tion, in both the general and veteran homeless populations, black race signi cantly predicts homelessness.4 Although


“Either (1) an unaccompanied homeless individual with a dis- abling condition who has been continuously homeless for a year or more, OR (2) an unaccompanied individual with a dis- abling condition who has had at least four episodes of home- lessness in the past three years.”5

any one individual’s descent into homelessness is multide- termined, many su er from mental illness, substance abuse, and unemployment and/or underemployment; some of these conditions may be military service-related.

e problem of contemporary homelessness captured federal attention in the 1980s; homeless people became visible beyond skid row, and a large number of homeless people had behavioral health disorders. In 1987, Congress passed the Stewart B. McKinney Homeless Assistance Act, which provided funding for a range of services to home- less adults, including emergency shelter, transitional hous- ing, job training, primary health care, and some permanent housing.

ese programs emphasized the importance of asser- tive outreach in nontraditional settings (on the streets, in shelters, and in soup kitchens), the process of engage- ment, intensive and long-term case management (includ- ing smaller caseloads and community-based care), mental health and substance abuse treatment, and rehabilitative services.6

Over the past three decades, there has been substan- tial progress in developing evidence-based practices for serving homeless people with behavioral health disorders. Permanent supported housing (permanent housing with mental health and wrap-around case management services) has emerged as a central strategy for improving housing outcomes for persons who have been chronically homeless, most o en with behavioral health disorders. Two evidence- based practices that are e ective in treating homeless peo- ple with behavioral health disorders are (1) the Assertive Community Treatment (ACT) model, a team-based model of care that involves providing services to people in com- munity settings; and (2) Critical Time Intervention, a time- limited and intensive case management program designed to assist people through transitions from homelessness to housing.

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), approximately 30% of individuals who are chronically homeless have a serious psychiatric disorder, and about 50% have a co-occurring substance abuse problem.7 Although studies on the preva- lence of comorbid psychiatric and substance use disorders (SUDs) among homeless adults are limited due to small sample sizes and limited geographical areas, there is evi- dence of a high rate of comorbid psychiatric and SUDs among homeless persons. Sullivan and colleagues8 examined data on a course-of-homelessness study of 520 homeless persons in Los Angeles over a 15-month follow-up period and found that people with psychiatric disorders, compared to those without psychiatric disorders, were more likely to



have a comorbid SUD. Furthermore, approximately half of homeless veterans have SMI,3 and both general and vet- eran population studies demonstrate that SUDs are among the strongest predictors of homelessness.9,10 With high rates of post-traumatic stress disorder (PTSD), TBI, and sexual trauma among veterans, all three are risk factors for homelessness.3

Community mental health agencies must provide a range of treatment, housing, and rehabilitative services that integrate medical, mental health, and social services. Since public-sector agencies are o en overburdened with indi- viduals already receiving services, it is o en a challenge to prioritize services to homeless people who are not seeking treatment, particularly when they only want community resources (see Chapter 6 on Community Supports and Inclusion).


During an initial assessment of a person experiencing homelessness, the goal is to triage for safety and then con- nect the person with the most appropriate community resources and services. Assessments will di er based on where the person experiencing homelessness is encoun- tered. When assessing a homeless person in the commu- nity, it is important to pay attention to the physical safety of his or her living conditions (e.g., in condemned build- ings), exposure to extreme temperatures, and interpersonal violence risks such as being victimized or preyed upon by others (e.g., domestic violence, gang violence, decreased cognitive abilities, living in a dangerous neighborhood). In these situations, there also may be a limited window of time in which the person will feel comfortable speaking with a practitioner. When assessing a homeless individual, there is also less need to