RESEARCH ON FIELD-BASED SERVICES - MODELS FOR REFORM IN THE DELIVERY OF MENTAL-HEALTH-CARE TO POPULATIONS WITH COMPLEX CLINICAL PROBLEMS

Objective: Clinical services for psychiatrically impaired populations have only recently been studied with scientifically valid designs to e xplore innovations in structure, accessibility, and financing. Health systems reform in the United States has provided the impetus for bette r defining clinically effective and cost-sensitive models for mental h ealth services. This article reviews assertive community treatment, us ed for adults with severe mental illnesses, and multisystemic therapy, used for adolescents with serious emotional disturbances, as examples of service system innovations that have been studied with controlled clinical trial designs and have demonstrated efficacy in treating diff icult and costly clinical populations. Method: The authors reviewed th e Published controlled clinical trials of assertive community treatmen t and multisystemic therapy, focusing on the clinical and administrati ve elements that distinguish them from traditional service systems. Re sults: A qualitative assessment of these two approaches suggests that they share common elements, with important implications for mental hea lth policy. Specifically, the use of an ecological model of behavior a pplied to mental health patients is critical to both systems. In addit ion, therapeutic principles emphasizing pragmatic (outcome-oriented) t reatment approaches, home-based interventions, and individualized goal s are key elements of their success. Most important, both systems embo dy a therapeutic philosophy demanding therapist accountability, in whi ch personnel are rewarded for clinical outcomes and therapeutic innova tion rather than for following a prescribed plan. Conclusions: As empi rically tested approaches, assertive community treatment and multisyst emic therapy provide a scientific foundation for continued reform and serve to illustrate critical elements in designing new community treat ment initiatives for behavioral as well as medical conditions.