This constructivist grounded presentation is the long-overdue proposal to close all “extended care” state level wards and discharge all remaining patients to a lower level of care. From long-term care and extended service units to admissions and adult, children, and adolescent services provided by inpatient treatment wards, this is a call for the complete discontinuation of long term state-level care units in state level treatment centers in the United States through the commission, implementation, and commission of WCTs Ward Closure Teams. No question, society has arrived at a crossroads in determining the future of mental health treatment. Consumers and practitioners both acknowledge that the current mental health system does not address gaps in mental health care and treatment. Instead, the system is still informed by the era of institutionalization and does not facilitate access to services at the local level where the potential need for connectivity and person-centered care is greatest. This paper dispenses a new term in being: WCT Ward Closure Teams and marshals new recommendations to challenge the ongoing denial of full community access to and integration of mental health care in the United State. Aiming to disrupt the increasingly insidious neo-institutionalization, this writer intends to make visible the theory that access to mental health treatment should be the first priority in addressing the mental health crisis at stake for consumers who have historically fallen through the cracks of the system. Mobilizing the perspective of a peer diagnosed with a mental health condition, I propose to create and establish new WCT practices and regulations to guide the revision of the system of care and public health policy in the United States.
Keywords: extended care, state hospital, mental health treatment, institutionalization, WCT Ward Closure Team
The discontinuation and closure of long term state level psychiatric units
I will never forget the words my psychiatrist in the community hospital in which I was receiving treatment for first-episode psychosis: “You’re not going to like where you are going….” (Personal Communication, 2008). My doctor was referring to the local state hospital in which I was pending immediate transfer for “unresolved psychosis” for “ongoing” care. I am a consumer of mental health services who has been hospitalized in a state psychiatric center in New York State. I am also a social worker, a disability rights advocate, and therapist for mental health treatment. This presentation will offer facts, data, and professional analysis based on years of clinical practice. In addition to clinical experience and research, I will incorporate the peer perspective stemming from my own experience and the shared experiences of peers in the United States. Utilizing peer-informed literature written by consumers of treatment in New York State and from other state-run regulatory bodies in the United States hiring peers, this paper presents a new perspective on uses of long-term hospitalization at the state level. The argument builds on existing research suggesting the state hospital system needs to be expanded and reformed. Instead of supporting this claim, I turn this fallacy on its head by reexamining the data already presented by supposed independent researchers contracted by the state governments from which they receive funding, which provide data and analysis of trends in modern mental health within the same system in which they serve.
In the research report written by Parks & Radke (2014) state psychiatric hospitals are a vital part of the continuum of care and should be recovery oriented and integrated with a robust set of community services, the authors lay out a set of recommendations on how to reform and revamp the existing state-run mental health system. The central arguments proposed then were not exactly new, nor a radical departure from standard practice in psychiatric medicine during the 1980s, shortly after the beginning of deinstitutionalization when clinicians were forced to accept that patient involvement in their own care should be central in the recovery progress. This notion, radical then, was driven by the peer movement and disability rights advocates passionate about changing clinical practices at the ground level. On a more global level, the report hammers existing roadblocks in the culture and environment of state psychiatric hospital facilities posing as barriers to providing effective care given new recovery-oriented; trauma-informed; culturally and linguistically competent regulations for best practice. These include patients receiving treatment in the “least restrictive environment possible” Parks & Radke (2014) and other peer–driven, recovery-oriented practices, such as including recovery specialists as equal members of the treatment team.
Unfortunately, when considering praxis in contemporary state-run facilities day-to-day operations, theory is not congruent with practice on the units and wards where patients live out their lives when treatment fails them in the community hospital. The very language, “when treatment fails,” is the point of departure for this argument, which questions the complicity and ethics of practitioners who consign their patients to the categories of “failed” or “untreatable” (Guttman, 2018) instead of an immediate revision or urgent critique of the praxis existent in available mental health treatment. The first step to providing the least restrictive measures possible in treatment is dislodging the use of restraints, including seclusion practices that isolate patients from their community members on the unit. In reality, from both professional and lived experience, state-operated units are smaller, more confined, overcrowded, and jail-like in architecture and lay-out of services in the wards. In addition to the aesthetics of institutionalization and the confining environment of the hospital, the restrictions placed on the patient living away from the community-at-large in a locked hospital, usually hundreds of miles away from family and friends, is antithetical and a sharp departure from the words and language used in the report by Parks and Radke (2014). It is, instead, the very reason why this presentation seeks to reevaluate so-called reform in today’s mental health system discussed by Spindel, P., and Nugent, J., (1999).
Research supporting the further expansion of the state hospital system continues to acknowledge the lingering debate about whether patients can be better served in the community in place of in-voluntary treatment in long-term state-run units. Given this debate still persists, government stakeholders and decision-makers need to give more consideration to both sides of the argument and truly look at the facts. Instead, revenue, insurance, and cost-based analyses of the situation continue to be firmly in the hands of the people that keep the system running. This presentation is instead independent of OMH (Office of Mental Health), DOH (Department of Health), and other federal commissions that hire researchers based on trends in funding and insurance reimbursement. At the crux of it, both sides of the community versus in-patient debate realize the risks and benefits patients must be evaluated at all times to determine if this same treatment in the state hospital can be safely provided in community settings.
In a report written by NASMHPD, states that in the year 2012 alone, over 40,000 patients across the United States were currently being housed in state level psychiatric centres. One day, state psychiatric centers and mental health hospital networks will be just relics, anachronistic holdovers of modern medicine and the sins of psychiatry. Where the last great psychiatric cathedrals now stand is a carefully laid out and organized system of hospitals. These hospitals continue to symbolize the harmful power that housed an entire population of “sick” people gone “mad” in hallways of the living damned. Hallways of “treatment” rooms in which medical interventionists forced medication, shock treatment, and lobotomies upon patients. While the mentally ill suffered and were exploited by medical testing, more insidious and covert forms of treatment were also administered. Indeed, lobotomies were supplanted by shock treatment and, the final abuser, the pharmaceutical companies. All of this set the stage for a canon of psychiatric atrocities as the 21st century unfolds. Today the legacy of state psychiatric center in the United States is being challenged by former patients, psychiatric survivors, and peers whose goal is to liberate medicine from psychiatry. This movement began in the 1970s and will reach its crescendo when the last patient is discharged and walks free past the gates of these institutions.
Still, research funded and disseminated by organizations like the Treatment Advocacy Center (TAC) and other reports which inform the emerging trends in state funding continue to be off the mark. Indeed, forced treatment and assisted out-patient care needs to be continuously reevaluated and reconsidered in the context of new emerging treatment options available for consumers which could benefit from release from psychiatric hold and deferred recovery due to problems rooted in access and connectivity to care. However, the reports generated by TAC and other advocacy organizations which put “treatment” ahead of the needs and voices of the consumers truly requires more careful consideration on the part of lawmakers, and stakeholders making decisions on how day-to-day operations are carried out by practitioners in state-run units than simply blanket appraisal and adoption of their recommendations. These are recommendations which continue to ignore the reality of life on the unit, and condemnation to extended and “on-going” treatment without consent and, even worse, effectiveness in avoiding re-hospitalization and certainly not expedited discharge to the community.
The writing in this presentation, its contents, and history began as chatter, “shop talk” among peers in community mental health center. But talk disseminated quickly, moving among the ranks of the peer movement to the level of the czar. The czar, leader among the peer movement, must finally end an era of institutionalization. The specter haunting consumers of mental health treatment even today, disguised as Neo-institutionalization and passed off as treatment to patients in the state hospital system must be stopped. In no uncertain terms, the czar must stand before the state government in New York State and United States federal government Department of Health (DOH) and set the deadline for New York State and all state-run psychiatric center to comply with ward-closure teams, and sign off on the discharges of all patients in the state hospital system. Indeed, under “article zero”, a future Office of Mental Health regulation, ward closure teams will be charged with the organization, dismantlement, and discharge of patients in state-run long-term and extended care units across the United States. A grand consortium of peers, social workers, and psychiatrists will be assembled. Once article zero is written into law, something Teague, G.B., PhD., Bond, G.R., PhD., Drake, R.E., MD, PhD., (1998), set as the true limits of establishing any best practice, high fidelity model, reproducible and EBP informed, studies and further manualizing of WCT can truly begin and offer tested evidence to this constructivist presentation.
Defining the problem: access to outpatient services, and the theoretical structure, composition of the Ward Closure Team WCT
Defining the problem
As with all things absolute, an exception to the rule always exists. For all that rule, including the czar, peers themselves must answer calls from all victimized people who demand and deserve justice. This is a justice as visible and clear as day to patients as the same euphonious chatter from the community center we peers would commensurate years ago and long before the last discharge. Until everything changes, and patients can see the specter rise in the gaze of their abusers, power and privilege will be restored in the hands of the consumer. Without question, full integration and access to mental health services resides in the community. To fully integrate services and consumers into the network of already available mental health programs, remaining patients in long-term state psychiatric centers must be discharged and released from the eternal holding pattern to ultimately integrate and help consumers gain access to community resources, and most importantly, to allow them to live amongst other people outside the gates of the institution. Therefore, phase one of the ward closure team manual for community access will target the release, discharge and reintegration of patients into the community. Later phases and future research will target the establishment of reliable systems of care in which chronic and high-risk patients will have reliable access to services and programs that will benefit this group in lieu of hospitalization.
Access to outpatient services
This plan begins theoretically at the level of local and state governments and municipalities that govern the regulation of mental health treatment: the state mental health authorities. The commissioner of each state mental health authority must ultimately approve this document and other similar research related to the mass-organized discharge of patients in psychiatric centers. Thus, state mental health authorities, the National Association of State Mental Health Program directors NASMHPD, in collaboration with federal agencies, must approve funding for ward closure teams to infiltrate and access state psychiatric hospital operations and systems at all levels that impact discharge planning and community reintegration. In theory, each freestanding unit in all state hospitals will work side by side with its assigned ward closure teams. Social workers, psychiatrists and all inpatient staff charged with the successful discharge of its patients must partner with the ward closure teams until the final discharge from the hospital in which the final patient reenters the community.
The crux of phase one is the funding needed to staff the ward closure teams across the states. Each team will serve as an interdisciplinary reflection of the treatment gaps identified at each hospital’s locale. This means that prior to each ward closure team beginning its work in a unit, the hospital will send a memorandum of requirements to the office of mental health, which will inform the makeup and composition of the teams assigned to each hospital and community. Thus, needs related to transportation and rural concerns will be managed by ward closure teams specializing in the needs of rural communities and their mental health systems. More urban-based communities with complex spatial and access issues will be staffed with workers adept at handling the mental health concerns of patients in urban settings.
The Ward Closure Team
The ward closure teams WCTs are a multidisciplinary, mobile field unit, and treatment team operated and regulated by state mental health authorities. Each team will be trained to target chronic diagnoses, relapse prevention, and offer treatment in a flexible, organic, person-centered approach. While the WCT and ACT team are similar in composition, in keeping with Evidence based practices EBP, the the potential for the WCTs positive impact on clients and, in turn, likelihood for good outcomes couldn’t be more radically different. ACT teams meet with clients for a minimum of 15 minutes of face to face contact to able to bill and consider the home visit a session, While sessions usually run longer, as patients typically have errands or complex case management issues or need transportation to medical appointments to and from treatment, or any number of complex case management issues the WCT clinician or peer needs to address in session, 15 minutes alone, is simply not enough time for patients discharged from state hospital step down units. In keeping with this premise, the completion of tasks patients typically request help with, or just requiring the attention of the worker go on and on, There is a laundry list of needs patients have after discharge from the highest level of care. It’s immense, overwhelming for clients still symptomatic and clinically determined to be safe, stable, and ready for re-entry into the community.
Integrating into the community is a challenge without a mental health disorder which distorts, complicates, and makes the vast obstacles ahead seem almost insurmountable. At the root of it, these aren’t clinical issues, but complex case management issues i.e. connection to medical providers, food shopping, obtaining hygiene and other household products due to transportation issues. Many clients surrender their drivers licenses prior to admission to the hospital due to legal, or some mishap and unfortunate circumstance. In many cases, due to high caseloads, productivity requirements, and other extraneous non-clinical issues, sessions times are limited, cut short, or only begin to address these serious problems patients struggle with upon re-integrating into the community. So, upon initial integration to the community, WCT teams sessions will be longer the length to bill for session under Article Zero and count the contact as a required visit. Similarly, instead of a minimum of six contacts a week with each client on the census, required monthly contacts, in this writer’s opinion, should also increase. Simply put, for WCTs to consider the patient enrolled under the care of the WCT, sessions should be doubled in length for clinicians and peers to be effective the upward mobility of a patients recovery.
Implementation: the methodology, phase I, II and III
The planning involved for both the ward closure teams and the existent treatment teams in the units surpasses the assessment of the composition of the community. Indeed, ward closure teams will be required to have a full understanding of local existing services in the community and will work side by side with treatment teams in the units to identify issues foreseen prior to each discharge. Hence, issues of adherence will be measured against connectivity issues in the communities’ existing health care networks. Other issues, such as medical comorbidities, will necessitate ward closure teams to acquire a full understanding of existing health networks that serve clients with complex medical and psychiatric issues and other complex case management services, which freestanding clinics do not traditionally provide. Simply put, WCTs can supply case management services to users dependent on the system of care after discharge from the hospital, and its vast and complicated services. Given the freedom to complete more case management services, while also providing clinical services, and be the primary point person in consumer care, time consuming and high impact complex care management tasks can be completed without incident, including certification and recertification of benefits to continue all of medically necessity are completed so services run without interruption. Under Article Zero, the incentives to learn, either through continuing education, but either way, certified in new treatment modalities which are proven through evidenced based studies to improve the prognosis of chronic patients being discharged from long term care settings e.g. state hospitals isn’t just to experience better outcomes for clients, but also build a track record as a practitioner.
So, all new and existing treatment team on the state hospital grounds as well as treating patients discharged from a state level facility will be required to be versed and certified in POD (Peer Supported Open Dialgoue), CBT-P(Cognitive Behavioral Therapy) targeting psychosis, delusional disorders, and a range of diagnostic interventions commonly associated with patients with chronic disorders. Thus, diagnostic and public policy stakeholders of health and medicine and public policy stakeholders all suggest Assertive Community Treatment (ACT) or PACT in some states should be re purposed, and selected as the best available discharge plan after graduating from a step down unit in a state hospital. In addition to being a mobile unit, care managers, and discharge planners for high risk patients will benefit by beginning treatment within the walls of the hospital, something ACT teams are limited to do, and according to state regulations and program guides, in New York State, and can only perform two “hospital visits” per month to bill for, and maintain the client on the team’s census. Thus, in addition to being more versed new EBP, WCT teams benefit from operating in the same physiological space as patients treatment team on the unit, a length of time which can be determined state to state, but always able to fully operate at two polarities, the highest level of care and conversely, the least restrictive environment possible, that is, within the community. Upon discharge, patients still under the care of extended care, will step down to transitional units, sometimes called TCU, WCTs can begin their field work inside the hospital unit, and plan to one day complete home visits upon their patients successful discharge from the step down units or TCU inside the facility to the care of ACT or PACT, and, under the provision of services for an undetermined, if necessary, permanent treatment team of patients determined by individual state mental health authorities, to require its care which is already prescribed by ACT or PACT Guidelines for practice, across states, Alberto B. Santos (1998) and in A Manual for PACT Start-Up Deb Allness & William H. Knoedles, (1999).
Prior to discharge from the hospital, and incongruence with regulations in several states (NY, NJ, CT, etc), discharge planners across all state facilities will have the responsibility of preparing all clinical treatment plans up for review for immediate step down to a lower-level of care. In doing so, the time-table will be set. While is some states, plans are reviewed every six months, others three, regardless of the lifespan of the plan, personnel in the hospital documenting the transition of patients to the community. Thus, discharge planners will begin to put paperwork into place which will follow clients records to the treatment teams in the community which will continue care upon re-integration.This means, across longer term care units, state hospitals will internally re-configure their units, to prepare for the large volume of clients discharged from the facility.
Without question, this, will in turn, serve remaining patients well who are mandated by the court, and largely, the criminally insane. This subgroup of the state hospital system, according to reports written by NASMHPD, are mostly forensic patents, not including sex-offenders, which make up a fraction of the entire state mental health system census. I am suggesting by emptying out and closing down long-term units containing nonviolent mentally ill patients, all remaining units will more likely be less crowded, better staffed with additional funding now less spread across fewer units. This has proven to reduce the likelihood of conflict and reduce safety issues on the unit in which clients whom are extremely agitated react, or act out against their peers, and other patients. When this plan goes into effect, all patients will less likely be exposed to violence. With more money to go around, new spaces, and units with a lower census, for more personalized, person-centered, and safer environment will blossom at the state level.
The last segment of phase one is the expansion of state level step down units. In various states, including many on the Northeast, Midwest, and West coast of the United States, step down units are too frequently used to transition patients back to the community. In many state facilities, including GBHC (Greater Binghamton Hospital Center), RPC (Rockland State Psychiatric Center), and several other state hospitals, only one or two transitional units exist. In theory, all patients in extended care and long term care units will be transferred to the transitional units available in the facility. Upon the patients’ treatment plan review date, all new plans requiring an update, will, in turn, determine the potential date patients are transferred from long term units, to the transitional care unit. This is the spark that will light the the fire that signals to the inpatient treatment team that new patients now require the attention of hospital staff to determine the long and short term planning necessary to begin to successfully discharging patients from long term units to a lower level of care. This lower level of care, specifically the transitional units available in the facility, will then prepare them selves for new admissions internally transferred from all remaining long term units. Should, given an analysis of the volume of patients being transferred internally, and ultimately discharged from the transitional unit to the community, this writer recommends the immediate allocation of funding to the creation, and expansion of transitional step-down units.
To achieve the desired goal, the next major step is implementing phase phase two which begins just after the assignment of ward closure teams to respective communities and state psychiatric centers. At this point in the plan, ward closure teams of new hired personnel, and even those transferred internally, composed of staff from units farmed-out and closed down after the facilities re-configure their census and disbursement of the hospitals population, patients needs prior to, and after discharge. These ward closure teams will target, and be staffed by personal able to target and specialize in specific diagnoses, and be prepared for less than promising patient prognosis, Upon gaining access to inpatient services, hospital operations, will begin working side by side with existing hospital staff. Teams will identify all remaining concerns for patients prior to discharge. This will be a process in which patients will work voluntarily with newly instated ward closure teams and contract to work with treatment teams in the community earmarked for their care post discharge.
Thus, all services will be matched with the needs identified by both the long-term and long-standing clinicians assigned to each unit and patient, as well as the newly commissioned closure teams to achieve the primary goal, which is complete access and the integration of all state hospital patients still in long term care back into the community and the end of institutionalization forever.To achieve this aim, the plan and each of its phases require not only community support and support from stakeholders regarding mental health and public policies but also the shared dream and goal of creating a society without walls or restrictive barriers for patients with chronic and long-term mental health conditions who are typically assessed and slated for long-term, ongoing, round-the-clock care that a state institution provides. Thus, the vision and scope of this proposed plan and the prospective teams charged with implementing the final solution and ending the era of Neo-institutionalization is clear: full community access to and the integration of all community mental health programs as well as the elimination of a level of care that is both dated and obsolete in the context of the full meaning of deinstitutionalization.
Studies continue to evidence the positive trend which suggest people, regardless of their precipitating reason for admission to the hospital, whom are supported in their discharge from long term units, eventually transitioned to a lower-level of care without incident, and provided access to community resources and mental health treatment are much more likely to succeed in the community than patients either clumsily discharged or without adequate planning. Thus, this three phase plan lays out a comprehensive third phase. In keeping with the assumption, ACT Teams continue to further more and more empirical evidence of treating the most chronic, and at most imminent risk of self harm or harm to others, ward closure teams will ultimately prepare their existing census for discharge to ACT Teams, the highest level of out-patient care and most effective Evidence Based modality across the United States for treating this population, So, since ACT Teams are already existent everywhere a potential patient is awaiting discharge from a transitional care unit in a corresponding state hospital, these ACT teams will absorb the majority of patients discharged from the ward closure team.
The transition of patients to their assigned ward closure teams will be synchronized, timed, and documented similarly to ACT treatment planning. Without re-creating the wheel for documentation in the field, ward closure teams will follow the free-wheeling, liberal documenting style and manner of capturing the patients clinical picture in the most representative and appropriate out-patient service. Since all out-patient mental health services are ultimately tied to coding, and congruent billing, ward closure teams will follow the coding of ACT services, so the creation of new medical billing questions do not interfere with the speed and necessity of discharge. Thus, ACT teams be able to replicate the practices and treatment of ward closure teams, and the continuum of care will be intact through from the moment the patient is discharged from the state hospital and fully transitioned back to the community, without anyone falling through cracks due to insurance, poor planning, or inadequate services after discharge from the hospital.
The end of Neo-institutionalization
Mental health is a community and public health need, and after implementing the proposed plan, the fallacies and misnomers of the old system shall never again point towards institutionalising people and sending the ‘problem’ patients to long-term care units far from the community and its resources. Access to services must be provided, and new pathways must be engendered so that consumers can gain access to the many lines of care already provided by the systems of care in New York State and by all regulatory bodies with a vested interest in mental health treatment.Neo-institutionalization is complex and insidious, and it must end. Therefore, the focus of the ward closure operations manual is threefold. The first phase of operations targets the state psychiatric centers based on a global assessment of outlying communities and on the express needs of the consumers being discharged. The second phase targets the overhaul of treatment silos and installations already in place in the community that need more integrated access for consumers. No question, the resources already exist in the community, and this document proposes how to reconfigure existing structures that provide mental health treatment to serve patients.
The success of phase two depends on the elimination of freestanding treatment silos. This means that all treatment programs that discriminate and choose to openly serve only subgroups or ‘high-functioning’ patients will be given a mandate by the office of mental health to broaden their scope of services, or they will be subject to a loss of licensing and funding. An example of a program that only serves a small niche of ‘qualified’ patients includes outpatient settings that refuse to accept state-sponsored insurance for patients who are disabled and reliant on Medicaid and other service dollars. Conversely, treatment centers that offer services to all patients or that are cited for restructuring and successfully reconfigure their clinics, group practices and day treatment centers will be awarded funding to commit to on-site projects and community outreach projects to further extend services to the community.
The next and final phase of this plan after patients are assigned to ACT teams is an ongoing community mental health surveillance and hygiene study which will continue throughout reintegration and the patient discharge to the community. Upon the final discharge of patients from extended care units, and all existing treatment plans up for review have expired, the final discharge from the locale’s state psychiatric center will have walked out of the gates of the hospital. Under the assumption that the influx of thousands of newly discharged chronic patients will test the limits of the community’s local emergency rooms and community hospitals’ abilities to provide services and will largely increase the census of mental health treatment at health centers, a surveillance and hygiene study will bridge the existing gaps in each community during the critical phase of mass-organized discharges from state psychiatric centers. The study will be monitored and fed into a state-wide planning commission for full community access to and integration of mental health care. Next, a broader approach, including at the global level, can be implemented and used as a model for other state regulatory bodies interested in eliminating the dated level of care and the deferred recovery of patients.
At the root of it, the planning and hygiene study will ultimately be analyzed and measured against the restructuring efforts already underway in the community. The gaps in care identified based on the hygiene and surveillance study will be seriously considered, and once verified, local community mental health care planners, managers and stakeholders will be charged with identifying solutions to the problems. Given the latitude required to make changes at the local level, the recommendation is that county community mental health departments and Single Point of Access (SPOA) committees spearhead the final structural adjustments to the mental health care system. Ultimately, the Office of Mental Health will begin drafting new regulatory codes that promote and encourage the end of Neo-institutionalization. Thus, codes will be established that discourage extended hospitalizations and ongoing treatment plans without an end. While not forbidden, these treatment pathways will generate red flags at community mental health offices and in the OMH headquarters where programs are monitored for compliance with these new integration and access practices.
Ultimately, this proposal is essentially a recommendation and call for regulators at the state and federal levels to revamp and to raise the bar to promote the best practices amongst practitioners and public health stakeholders of mental health care. Research suggests that the delivery of mental health treatment must go on without interruption from either hospitalization or from falling into a gap in available treatment at the local level. Given that many community treatment settings are either inaccessible or do not target the provision of resources for patients to continue recovery on their own terms and in their own communities, it can be assumed that the next logical step in creating a culture equipped and prepared to address mental health care crises will require practitioners and law bodies to pay close attention to this recommendation with due diligence. The rollout and the implementation of ward closures in the United States and anywhere that patients are in a psychiatric holding pattern without hope of accessing services in their communities is urgent.
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