Test, and Stein conceived this idea in 1973 in Madi-
son, Wisconsin, while working at Mendota State Hos-
pital. They believed that skills training, support, and
teaching should be done in the community where it
was needed rather than in the hospital. Their program
was first known as the Madison model, then “training
in community living,” and finally ACT or the program
for assertive treatment. The mobile outreach and con-
tinuous treatment programs of today all have their
roots in the Madison model (Hughes, 1999).
An ACT program has a problem-solving orienta-
tion: staff members attend to specific life issues, no
matter how mundane. ACT programs provide most
services directly rather than relying on referrals to
other programs or agencies, and they implement the
services in the client’s home or community not in an
office. The ACT services are also intense; three or
more face-to-face contacts with clients are tailored to
meet clients’ needs. The team approach allows all staff
to be equally familiar with all clients, so clients do not
have to wait for an assigned person. ACT programs
also make a long-term commitment to clients, provid-
ing services for as long as the need persists with no
time constraints (McGrew et al., 1996). When par-
ticipants were asked which components of ACT were
most satisfying to them, they identified staff avail-
ability, home visits, and help with everyday problems
(McGrew et al., 1996).
ACT programs were developed and had flour-
ished in urban settings. Fekete et al. (1998) studied
the effectiveness of ACT programs in rural areas,
where traditional psychiatric services were more lim-
ited, fragmented, and difficult to obtain in rural areas
than in cities. They noted that although 20% of the
U.S. population is rural, 33% of the poor population is
rural. Therefore, rural areas have less money to fund
services. Further, social stigma about mental illness is
greater in rural areas, as are negative attitudes about
public service programs. The study found that ACT
programs were successful in rural areas and resulted
in fewer hospital admissions, greater housing stabil-
ity, improved quality of life, and improved psychiatric
symptoms. This success occurred even though certain
modifications of traditional ACT programs were re-
quired such as two-person teams, fewer and shorter
contacts with clients, and minimal participation from
some disciplines.
Bond, Drake, Mueser, & Latimer (2001) report
that ACT programs continue to succeed in providing
more cost-effective alternatives to hospitalization
while improving client satisfaction with services. They
also identify areas that ACT programs need to address
more effectively: vocational focus, social skills train-
ing, development of social networks, and working with
family members. The authors believe these areas are
within the scope of ACT and would enhance the re-
covery of clients in the community.
SPECIAL POPULATIONS OF CLIENTS
WITH MENTAL ILLNESS
Homeless
Homeless people with mental illness have been the
focus of recent studies. For this population, shelters,
rehabilitation programs, and prisons may serve as
makeshift alternatives to inpatient care or support-
ive housing (Sullivan, Burman, Koegel, & Hollenberg,
2000). Frequent shifts between the street, programs,
and institutions worsen the marginal existence of this
population. Compared with homeless people without
mental illness, the mentally ill homeless are home-
less longer, spend more time in shelters, have fewer
contacts with family, spend more time in jail, and face
greater barriers to employment (Haugland et al.,
1997). For this population, professionals supersede
families as the primary source of help.
Kuno, Rothbard, Averyt, & Culhane (2000) found
that an enhanced community-based health system
was not sufficient to prevent homelessness among
high-risk people with mental illness. Likewise, pro-
viding housing alone does not significantly alter the
prognosis (Dickey et al., 1996). In a study conducted
in Boston, homeless people with mental illness were
given permanent housing in an apartment or an ECH,
access to mental health treatment, and specialized so-
cial services. There was no difference in the housing
stability of the two groups based on the type of res-
idence. Both groups significantly increased their hous-
ing stability and use of mental health treatment
services. Similarly Shern et al. (1997) followed 896
homeless mentally ill adults in four major cities. After
receiving stable community housing, community sup-
port, and rehabilitation services, 78% of the partici-
pants were housed stably at the 12- to 24-month final
follow-up. Chinman, Rosenheck, & Lam (2000) found
that homeless clients who had a positive relationship
with their case manager had fewer homeless days and
higher general life satisfaction than clients reporting
no relationship with their case manager.
The success of such projects suggests that it is
possible to make significant differences in the lives of
mentally ill homeless by providing active psychiatric
rehabilitation services along with housing alterna-
tives. The Center for Mental Health Services initiated
the Access to Community Care and Effective
Services and Support (ACCESS) Demonstration
Projectin 1994 to assess whether or not more inte-
grated systems of service delivery enhance the quality
of life of homeless people with serious mental dis-
abilities through the use of services and outreach.
ACCESS was a 5-year demonstration program with
locations in 18 communities of 15 U.S. cities, repre-
senting most geographic areas of the continental
United States (Chinman et al., 1999). Each site pro-
vides outreach and intensive case management to 1004 TREATMENTSETTINGS ANDTHERAPEUTICPROGRAMS 79