Another article by these authors on this subject, Polar Opposites, will be published in the next issue of the Ethical Human Sciences and Services journal put out by Springer Publishing. An article written by Dr. Tomi Gormory on PACT appeared in that journal in Summer 1999, Vol 1, Number 2.
THE TROUBLE WITH PACT
QUESTIONING THE INCREASING USE OF ASSERTIVE COMMUNITY TREATMENT TEAMS IN COMMUNITY MENTAL HEALTH
©PATRICIA SPINDEL and JO ANNE NUGENT
Humber College of Applied Arts and Technology
This article is a critical analysis of the PACT model. It encompasses three major areas of identified deficiency philosophy, research, and practice. The authors reveal the biomedical bias of PACT, and critique its social control features. They also examine how PACT may prevent the building of community supports for individuals with serious mental health issues rather than promoting them.
A DEFINITION OF PACT
The Program for Assertive Community Treatment (PACT) derived from the Training in Community Living Program (TCL) in Madison, Wisconsin. It is an approach which features the use of a team, rather than individual case managers, to provide continuous, ongoing service to clients who need high levels of support. Some of the goals of this approach are to "stabilize symptoms, prevent relapse, meet basic needs, enhance quality of life, and optimize instrumental and social functioning" (Test, Knoedler & Allness, 1992, p.684).
The PACT model of case management has several phases Engagement, Stabilization, Maintenance of Ongoing Treatment, and Discharge. During the Engagement phase, a trusting relationship is developed between the treatment team and the individual. This is considered to have been successful when the treatment team is identified as a client's service provider (Dixon, Krauss, Kernan, Lehman, & DeForge, 1995). The Stabilization phase is considered to be a skill-building period aimed at creating a more stable lifestyle within the community. Practical issues like housing, income, and the establishment of a daily routine are addressed. Goal setting is done collaboratively between the team and client. During the Maintenance phase, emphasis is upon keeping the gains which clients made in the Stabilization phase.
Finally, clients are usually discharged after they and staff agree that the client's goals have been met, and a less intensive program can take over (Dixon et al, 1995).
THE TROUBLE WITH PACT
Troubles with PACT arise in three distinct areas philosophy, research, and practical service delivery.
Philosophically speaking, PACT is essentially a biomedical model, with specific social control features. Drake and Burns ( 1995, p.667) have put it succinctly "The central idea of assertive community treatment was that a community-based team would provide a full range of medical, psychosocial, and rehabilitative services, analogous to care in a hospital, to prevent hospitalization of clients.....". Burns and Santos (1995, p.669) also described assertive community treatment as "much like hospital-based treatment...intended to be continued on a long-term basis, so that patients do not lose the benefits of treatment due to changes in settings or providers, or due to inadequate follow-up".
PACT has been said to implement an "aggressive" approach to symptom reduction (Burns and Santos, 1995), and to prevention of relapse. Assertive community treatment team members will "provide home delivery of medications" and "actively monitor clients' physical health care" (Drake and Burns, 1995, p.667). There is an emphasis on "medication compliance" in some studies on PACT (Drake and Burns, 1995; Burns and Santos, 1995).
For over twenty years, the biomedical approach has been repeatedly criticized by psychiatric survivor groups and numerous authors, as being too drug-oriented and too controlling (Blackridge & Gilhooly, 1988; Burstow & Weitz, 1988; Johnson, 1984; Ontario Coalition to Stop Electroshock, 1984; Breggin, 1983; Sterling, 1979).
Many of the PACT teams accept the presence of psychiatrists and nurses without much critical reflection, thereby reinforcing, without question, the notion that a case management approach with a built-in biomedical bias is desirable. One study revealed that 88% of 303 U.S. based assertive community treatment programs surveyed, had both nurses and psychiatrists on the treatment team (Deci, Santos, Hiott, Schoenwald, & Dias, 1995, p.677). That Deci and his colleagues saw nothing wrong with this is not surprising, since he and his fellow researchers are all tied to departments of psychiatry or biometry in South Carolina. Others have also written that "psychiatrists are an integral part of the team, and symptom stabilization is a central goal" (Dixon, Krauss, Kernan, Lehman, & DeForge, 1995, p.686).
The social control aspects of PACT are of some concern, since social control in treatment flies in the face of the progress which has been achieved in recent years, in introducing the concept of individual rights into treatment debates. One such right is the right to be left alone.
The potential for abuse of power is obvious in a biomedical model, and in a psychiatric profession which has, over time, engaged in practices like electroconvulsive "therapy", lobotomy, civil commitment, and which has ordered the use of chemical and physical restraints repeatedly. These "treatments" have generally been reserved for clients who have failed to meet the medical and nursing professions' criteria for self care, or appropriate and rational behaviour.
The use of extremely intrusive interventions in PACT have also not been questioned to any great degree. Assertive community treatment has been considered by Drake and Burns (1995, p. 667) to have obviated "the problem of missed appointments", and it has established 24 hours a day, seven day a week "education, support, treatment, and rehabilitation..... on a continuous basis, for an unlimited time.." This kind of intrusiveness is considered by many researchers to have produced positive results, but perhaps not by clients on the receiving end who have, in some studies, dropped out in large numbers (McGrew, Bond, Dietzen, McKasson, Miller,1995, p. 698) .
Because PACT has long been considered to be a program which can assist the "most seriously mentally ill", drop out rates may be informative. A study conducted by several authors comments on the fact that clients "referred from community mental health centers were more successfully engaged, while clients referred from shelters and hospitals were less successfully engaged" (Herinckx, Kinney, Clarke, & Paulson,1997, p.1298). Apparently some clients, no matter who attempted to "treat" them, were making it clear through their actions, that they would rather be left alone.
Another study (Solomon & Draine, 1995, p. 265), which examined, over a one year period, results from a randomized trial of case management clients leaving jails, found that more PACT clients (60%) returned to jail than clients of individual case managers (40%). Coercion may have played a role in this. The authors report that, "ACT case managers worked closely with probation and parole officers. When clients were found to be noncompliant with treatment, particularly regarding medication, they collaborated with these officers to reincarcerate the clients" (Solomon & Draine, 1995, p.267). It is notable that most subjects in this study reflected jail populations, and included a disproportionate number of black males. The clients in this study were not incarcerated because they had committed new crimes. They were incarcerated because they defied the social controls which were placed upon them.
For all of these reasons, the PACT model would seem to be a throwback to a time when the rights of those being "treated" were not of much concern to mental health practitioners. Certainly of not as much concern as addressing clients "best interests" in spite of their protests. This lack of regard for individual rights is sometimes called "benevolent coercion" (Mulvey, Geller, & Roth, 1987), but it can have very serious consequences for individuals, resulting in measures as extreme as outpatient commitment, or incarceration, as seen above. The degree to which current mental health workers and administrators are embracing PACT is particularly worrisome for this reason. It points to the absence of a grounding philosophy in community mental health practice, which has, at its base, a solid respect for the autonomy and rights of individuals, and which considers the serious personal and social consequences of removal of these rights.
A further indication of the lack of respect for autonomy and clients basic rights is found in the study by Deci, Santos, Hiott, Schoenwald & Dias (1995, p. 677). They found that 82% of 303 PACT teams surveyed, provided "financial management" of clients' money. This should have raised some concerns about social control. Controlling a person's finances is akin to giving professionals considerable control over clients' lives. The absence of apparent concern over study findings of this nature reveals a lack of critical examination by mental health workers, of the nature and degree of appropriateness of the social control features of their own practice.
In some cases, "medication management" and client compliance with taking daily medication were features of the approach. Deci et al (1995, p. 677) found that 80% of 303 PACT programs surveyed delivered medications. The emphasis placed upon medication management, and "managing difficult clients" points to a process which stigmatizes and labels people for not following the wishes of society in general, and their doctors and workers in particular. The direct experiences of clients, and the reasons for their "non-compliance" with others' wishes is almost never taken into account. In other words, individuals who do not comply with society's desire to see them behave differently, as acted out through professionals' attempts to cause them to modify or change their behaviour, are subjected to various levels of coercion in an attempt to obtain "compliance". This is clearly the language and the practice of social control, and it appears to arise from the way that clients are labelled and stigmatized by professionals.
In a related matter, Essock and Kontos (1995, p. 679) speak of "minimizing family burden" and "minimizing cost" in their article. This seems to say that individuals with serious mental illness are seen as "burdens" to be alleviated at the least cost to society. Other articles describe some people with mental health issues as "typically disengaged from services or likely to use inpatient or emergency services", hence they "need assertive outreach to link them to intensive, ongoing rehabilitative services" (Teague, Drake, Theimann, & Ackerson, 1995, p. 689). Nowhere is the experience of the client discussed, nor are the reasons why they are "disengaged" from services or from their friends, families, and communities. Being disengaged from services is seen as negative, and demonstrated proof that an individual is in need of "rehabilitation". If these criteria were applied to any other member of society, they would be seen as intrusive and disrespectful of individuals' rights to choose how they want to live.
There have been a flurry of studies recently concerning the PACT model. These studies may or may not provide an accurate picture of the success or lack of success of PACTs, and certain aspects of them deserve closer scrutiny.
Independence of Researchers
Several studies have been done by researchers who were not entirely independent of the programs being surveyed. The study done by Dixon et al (1995), shows that all of the authors were affiliated with the Center for Mental Health Services Research in the Department of Psychiatry, at the University of Maryland at Baltimore. The "Baltimore experiment" being studied, was the "experimental arm of a randomized clinical trial" which compared it to ordinary services which were not case management services. The study was done with a grant provided by the federal Center for Mental Health Services under the McKinney Act. The McKinney Act was signed into law in 1987 by President Ronald Regan. It was an attempt to address the issue of homelessness in the United States.
Essock and Kontos are both staff of the Connecticut Department of Mental Health. They reported on "a randomized, controlled trial of assertive community treatment at three sites in Connecticut" (1995, p. 679). Teague and Drake are both affiliated with the New Hampshire-Dartmouth Psychiatric Research Centre, which has, as one of its projects, "modifying the PACT model to provide integrated treatment for dual disorders" (Teague et al, 1995, p.689).
In other studies, the relationship between those being researched, and those doing the research was unclear (McGrew et al, 1995; Deci et al, 1995). In some studies, data was collected by case managers themselves through "clinicians' activity logs, case manager interviews with clients, or through internal management information systems (Teague et al, 1995, p. 690). Case managers sometimes made the determination about whether or not their clients' functioning had improved. Case managers also administered the structured interview used to gather some of the data. Case managers' perceptions were not always corroborated through observations by independent researchers (McGrew et al 1995).
Some researchers used structuralKey Words case management, assertive community treatment, social control, biomedical model. quality outcome measures such as internal agency documents on program implementation, policy and procedural manuals, and programs' mission statements and formal practices instead of direct observation of results. Some researchers visited the PACT teams once a month, and sat in on staff meetings, and had interviews with PACT supervisors (Teague et al, 1995, p. 690). Very little is said in most of these studies about whether or not clients provided much direct input to external researchers about their level of satisfaction with this model as opposed to other equally funded and staffed case management approaches.
There is a strong impression in some research studies of comparing apples to oranges. In most controlled studies there is an expectation that researchers will compare outcomes of programs with similar variables. That is not the case in some PACT studies where outcomes of well funded PACT teams were compared to underfunded, overworked individual case management teams client outcomes. In some cases questions could be raised about whether or not researchers were actually examining a PACT model, and there may not even be consensus on what constitutes a PACT model.
Deci et al (1995, p. 677) showed that only 45% of the programs examined, actually functioned according to a PACT model, in that teams shared a common caseload. Olfson also made this point. He noted that what is called "assertive community treatment" can be quite different from one area to another. The presence of other types of case management approaches has blurred the gap between the PACT approach and others (Olfson, 1990). Essock and Kontos (1995) have also raised the issue of whether or not time-limited assertive community treatment teams without fixed caseloads could be considered to be functioning according to a PACT model. And Solomon and Draine (1995) also questioned the issue of fidelity to a PACT model in their study of seriously mentally ill clients leaving jail.
It is important in any outcome evaluation to be certain that the model being studied actually complies with widely accepted criteria for that particular model. Otherwise, results attributed to PACT could be attributable to other practices which may or may not be part of what is commonly considered to be a PACT model.
Essock and Kontos (1995) have acknowledged that some studies of PACT may be flawed in that they compare "understaffed, overcrowded community-based programs" to "new, well-staffed assertive community treatment teams that gradually fill their caseloads". They have also characterized PACT as a "labour-intensive style of service delivery", studies of which have produced "very little data about who benefits from assertive community treatment and the cost of achieving such benefits"(1995, p. 679). These authors also questioned how much is actually known about what program components are important in achieving goals in functioning which are attributed to PACT.
The Essock and Kontos (1995, p. 682) study was flawed, in that of the 262 participants studied, 86% were white, and 64% were male. The significance of this was not discussed in the study. Race and gender issues can have a major impact upon the lives of people who have been labelled seriously mentally ill. The impact that discrimination can have upon peoples stress levels and subsequent rates of hospitalization and incarceration are highly relevant to outcome research in any study. Solomon and Draines (1995) study on clients labelled seriously mentally ill who were leaving jails illustrates this to some extent. Their study included a higher than average number of black males who had been incarcerated, and the results showed that the PACT case managers had collaborated with probation and parole officers to reincarcerate clients who were "non-compliant"(1995, p.257). Burstow (1992) has pointed out that the context of violence in which women often find themselves can have a very negative impact upon their ability to cope with pre-existing mental health conditions. Consequently, violence in womens lives may also negatively affect rates of hospitalization. PACT outcomes can, therefore, be questioned, when people of colour and women are in a statistically significant minority in these studies.
In some studies, many participants had dropped out within an 18 month period, and it was not always clear if the findings related only to those who were left in the study, or whether the drop-out rate was factored in. Would the views of those who dropped out have affected the degree of client satisfaction often attributed to PACT?
Some of the criteria used to rate the PACT model were also questionable. Self reports were used in some studies, without corroboration by independent indicators. In areas where PACT staff were managing client's money, the social control aspects of doing so, could have influenced results, but this was generally not discussed.
Two criteria which could be said to be more concrete than "quality of life" measures are employment status, and the level and degree of legal problems clients face. Authors who studied these two more concrete indicators found that either clients did not improve, or their situation worsened with a PACT model (McGrew, Dietzen, McKasson, Miller,1995).
Where PACT teams have utilized mobile crisis units, it is unclear whether the "success" of the PACT team was attributable to its own efforts or to those of the mobile unit.
Most studies appear to cover a relatively short timespan - usually two years or less. Since this is such a short time in the life of an individual with serious mental health issues, the conclusions may not be particularly valid.
In reviewing many of the PACT studies cited earlier, it is clear that the outcomes often attributed to PACT are questionable at best. Because of this, PACT requires much more research, and closer examination of other variables which may, or may not be contributing to the results being claimed for this model.
PRACTICAL SERVICE DELIVERY CONCERNS
PACT presents a series of challenges to clients which other kinds of case management approaches, especially those which employ an empowerment perspective, do not. These challenges may be particularly problematic if the focus is upon those labelled seriously mentally ill.
The Client Must Relate to Several Team Members
The client obtaining services from an assertive community treatment team must establish meaningful working relationships with a team, rather than just one person. It is well documented that the success of any professional intervention depends more on the quality of the relationship between the professional and the service recipient than on any other factor, including service model (Rogers, 1973, p.14). It is much more difficult, if not impossible, for any human being to establish warm, supportive, and trusting relationships with a "team". This is exacerbated when a client has mental health problems. Even the DSM-IV, used extensively by biomedical practitioners, lists inability to form stable, meaningful relationships as a primary symptom in a number of psychiatric conditions. Someone who already has serious mental health difficulties, and who may have problems forming satisfying relationships, will not relate easily to a "team" of workers. In the case of someone who is confused and perhaps disoriented, having to decide who is her/his point of reference on a team, may pose some difficulties.
It is also perfectly natural that some case managers may gravitate to particular clients and vice versa. This is a reasonable outcome, since it stimulates a more trusting relationship, when client and case manager have an affinity for one another. Having the same staff person see the same client again and again is frowned upon in assertive community treatment, and according to Essock and Kontos, (1995, p.683), needs monitoring to ensure that it does not occur.
Negative Stereotyping of Mental Health Services Recipients
Utilization of a team of experts creates a very negative image of service recipients. It implies that a client is so abnormal, bad, or different, that a whole team of people is needed to work with him or her. The message this sends to a community which does not easily accept people with psychiatric labels, may preclude attempts to reintegrate the client into any semblance of a normal lifestyle. The negative image created by having to work with a whole team may also have a devastating effect on the person. Far from seeing a person as having strengths, and creating a context for their empowerment, this kind of overprofessionalized, stigmatizing approach may destroy what little self worth, sense of belonging, and hope a client has.
The Professionalization of Individuals Needs
Many service sectors are currently emphasizing building supports for individuals in the community. This approach is being used with seniors, people who have AIDS, persons with developmental disabilities, and those who have psychiatric labels. While many people may require certain kinds of professional interventions, the goal is to reduce professional services to the minimum, while concentrating on alternative non-professional supports inherent in communities. Despite their labels, people need many of the same lifestyle elements as everyone else loving relationships, stable housing, reasonable income, meaningful activities, spiritual fulfilment, and development of the self as an individual. Such typical, positive experiences can minimize the reliance on expensive, controlling, and impersonal professional services.
By using a team approach, PACT flies in the face of this community-based trend, since it professionalizes peoples needs and entrenches an individual's reliance upon professional services.
Teague et al (1995, p. 689) have commented that PACT clients are "typically either disengaged from services or likely to use inpatient or emergency services; they need assertive outreach to link them to intensive, ongoing rehabilitation services". The objective here is not to build community, but to link to biomedical services.
A Lack of Emphasis on Community Building, Family, and Community Involvement
If natural supports which can be provided by the community, family, and friends are desirable, then the service system must be welcoming, easy to understand, accessible, and friendly. Teams are not user friendly. Confronting a team in a case conference can be intimidating for family and friends. Accessibility is reduced when a person's support network must try to form relationships with a team. With a very high level of professional support, family and friends are more likely to drop out of involvement with the person, assuming that the professionals are "taking care of it".
In contrast, the use of one community-based case manager, who understands the concept and practice of empowerment and building upon a client's strengths, can better stimulate the formation of a relationship with both a client, and where the client wishes it, with her or his family and friends. An empowerment-oriented case manager who knows a client well, is in a much better position to act as a true advocate and support to a person than a team is.
The grocery store owner who is a potential employer, the church goer, who is a potential social support, the neighbour who is a potential landlord, will not be encouraged to assist a person who is seen as requiring services from a whole team of professionals. This kind of approach is more likely to create distancing and alienation between a client and community people.
With PACT's assumption that professionals "know" and clients and family members "don't know", the PACT team's relationship to family members is more likely to be "educational" in nature, as described in Burns and Santos (1995, p. 673) "psychoeducation" approach. The implications of this "one-up" professional over non-professional belief system are obvious.
Team Politics An Unfortunate Side Effect of PACT
Working with a team requires team members to spend a great amount of time dealing with each other. Establishing authority, maintaining ongoing communications, fulfilling the agenda of one's own profession or department, are all realities of team work.
One case manager working with an individual can concentrate on supporting that person, and building a sense of community around her or him, rather than having to deal as much with team politics. While it is necessary for any case manager to be knowledgeable about team and inter-agency requirements, this can be a lesser priority in a one to one relationship, than it is when a full team is used to provide services. At least one study showed this to be true. Solomon and Draine (1995, p. 268) reported that, "ACT case managers were resistant to operating as a team on a daily basis. They stated that these clients had difficulty developing relationships and building trust with one person, and that relating to four people would undermine this process. This position was supported by the supervising psychiatrist". The clients to whom this study referred were those who were homeless, labelled seriously mentally ill, and who had been incarcerated.
Most studies of PACT have found two positive outcomes consistently - that PACT reduces the number of hospital admissions of clients taking part in the studies, and that clients report a higher degree of satisfaction with this model than with other types of mental health services (although it is not known what role social control features of PACT or drop-out rates may influence that, since these have not been studied). In the first case, there are no clear explanations of why this is so. In the second, the earlier criticism of comparing a well-funded and richly staffed service with others which are overcrowded and understaffed may apply.
Studies of the PACT model have not consistently shown that clients gain skills or develop the natural support systems they need to help them to live successfully in the community. The development and strengthening of natural supports, or the generation of new resources through non-professional human contact, are not mentioned in studies of PACT.
Advocacy on the part of PACT case managers, which is intended to confront systemic inequities that poor and labelled people often face, is also almost never mentioned in the PACT literature. Much of the literature is silent about the systemic impact of poverty and discrimination upon clients.
In recent years, the community mental health sector has said that moving away from a biomedical type of practice which is more in line with many consumers' wishes is desirable. Community mental health practitioners have also stated that they are not seeking to socially control their clients.
What is perplexing then, is that some community mental health programs appear to be adopting a case management model with significant biomedical and social control features, rather than adopting an approach which avoids these features, helps individuals to build natural support systems, and thereby increases, through human connection with non-paid people, their chances for more permanent success in community living.
One of the reasons why this is occurring may be found in the absence of a clearly articulated philosophy of practice in community mental health, which challenges both the biomedical and social control aspects of mental health practice. The absence of a philosophy upon which case management practice can be built, may account for the number of case management approaches which have been tried, then abandoned over the past number of years in community mental health.
Rather than adopting particular case management models, then attempting to justify their efficacy, community mental health programs may be better advised to adopt and articulate a philosophy of practice which informs the way all community mental health services are delivered.
Where practice fails to follow rhetoric, credibility becomes an issue. Community mental health programs claiming to believe in client autonomy and interdependence, will have to reflect upon the areas where case management practice incorporates more of a social control orientation than it does an empowerment approach. Programs which are seeking to veer away from a medical model, will have to examine more carefully where a medical/psychiatric bias continues to dominate their practice, and interferes with the development of more progressive approaches to working with clients.
Ann Hartman (1994, p. 171) has said in her work Reflection and Controversy, that as professionals "we have embraced this ideal [empowerment], [but] it may be that we have not really examined the dilemmas that emerge and the choices to be made when a profession adopts empowerment as a mission". She sees many forces - "institutional, economic, political, ideological, and historical" which may present significant barriers to professionals in any field adopting a truly empowering approach with their clients.
It may be that because many professionals in mental health have never actually examined their own philosophical and practical positions in their work with clients, that some may be accepting uncritically, the social control functions of their work. If this is occurring, then some workers, whether or not they are using a PACT model, may be engaging in "power over" interactions with their clients, quite unwittingly. The PACT model incorporates social control functions, which have been largely unquestioned by the field. This seems to point to the absence of a philosophical framework from which different approaches can be analysed for their moral and practical implications, and their impact, as actually experienced by clients.
The main trouble with PACT, and with many other case management approaches currently in use in the mental health sector, is that there has been no critical analysis of how personally empowering or socially controlling these approaches actually are. The other trouble with PACT, is that it does not rest upon a philosophical framework which stresses true empowerment of individuals. Important literature (Fooks, 1993; McKnight, 1995; Gutierrez, GlenMaye, & DeLois, 1995; Weedon, 1987; Rappaport, Swift, & Hess, 1984; Chapin, 1995; Weick, 1992; Hartman, 1992; Burstow, 1992; Zimmerman, 1990) which has been produced in recent years, and which questions the way that human services are delivered, is not considered in any evaluation of the PACT approach.
Considering some of the approaches outlined here which are used in PACT, it is clear that PACT does not meet the criteria for being an empowerment approach to working with disadvantaged, labelled, and stigmatized people. In fact, PACT may be little more than a means of transporting the social control and biomedical functions of the hospital or the institution to the community. For a community mental health system which says that it wants a more progressive approach, PACT simply does not fit the bill.
2. Structural measures refer to concrete mechanisms, such as policy and procedural documents. This is only one aspect of quality assurance. The other two are process and outcome measures.
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Key Words case management, assertive community treatment, social control, biomedical model.