Sam's story is terribly familiar and unfortunately not all that atypical. Sam reminds us that people with bipolar disorder may be only partially responsive to treatment, may deny that they are ill or need treatment, and may not experience the interepisodic return to baseline that we were taught is a distinction between bipolar disorder and schizophrenia.

What is probably atypical in Sam's case is the enormous amount of services he has received over the 20-year course of his illness and the continuity of his caregivers. Also, Sam appears to have been treated with state-of-the-art pharmacotherapy for his disorder. Also noteworthy are Sam's personal strengths: he has never abused substances, he has never been threatening or dangerous to others, he is intelligent, and he loves music.

Despite his extensive treatment and his strengths, Sam continues to deny his need for treatment and is dysfunctional even at his most stable times when medication is closely supervised. He discontinues treatment when not closely monitored and engages in behaviors that are both bizarre and a danger to himself. In this context, given unlimited resources, what should be done for Sam? The choice presented in the case summary is between continued community service as is, which is described as "maintenance in the community," or an extended hospitalization with a "rehabilitation push" in an effort to treat Sam and perhaps move him into a process of recovery.

Are these the only choices? Without question, Sam and his treatment team are stuck. Sam has had 20 years of biopsychosocial treatments that have been minimally effective. Weekly psychotherapy for two decades has not helped Sam enter a recovery process. Case management services have helped keep Sam alive but have not kept him from deteriorating. Sam has refused traditional community-based rehabilitation-oriented interventions. At his best in the community, with guardian-approved medication, he is withdrawn and isolated, with a predominance of what might be called negative symptoms. Sam needs to be engaged in a program that does not permit him to withdraw or refuse rehabilitation services. Such a program would provide the rehabilitation push. It would also clarify whether medication might be more effective if Sam were consistently compliant over time.

A highly structured program, using behavioral techniques and an emphasis on social and living skills training, can be effective for people like Sam (+1). His love of music offers a clear source of motivation for this otherwise frustratingly unmotivated person. Convincing Sam that he has reasons to get out of bed, get dressed, and participate in vocational, recreational, or social activities is essential for him to get unstuck.

Must this ideal program be hospital based? What if the treatment system cannot afford it? Stein and Test's assertive community treatment model (+2) was created to provide just this sort of intervention in a community setting rather than in a hospital, and it has been demonstrated to be cost-effective (+3). When assertive community treatment was designed, essentially the hospital team was deinstitutionalized and the full array of treatment and rehabilitation services was made available to a cohort of patients in the community with the high staff-to-patient ratio of a hospital. Assertive community treatment is a team model, taking advantage of the expertise of different professionals and paraprofessionals. Because the care providers operate as a team, rather than as a group of individuals, the chances for burnout are minimized. Assertive community treatment involves meeting the patient on his or her own turf, persistently and assertively offering assistance, and using motivational approaches and coercion when indicated. This approach has been demonstrated to be an effective intervention for most individuals with severe and persistent mental disorders. Clearly, Sam has been offered a great many services. However, it is unclear whether the services were ever coordinated and provided by an assertive community treatment team. If not, Sam deserves such a trial.

Understandable enthusiasm about assertive community treatment as the intervention of choice for someone like Sam has led to the notion that this approach, when undertaken with fidelity to the model, will ultimately be successful. However, many clinicians believe that some people fail in the community despite the best efforts of an assertive community treatment team. Such people require more structure and support than even the team can provide. These individuals seem unable to manage the freedom and lack of structure found in the community. I suspect Sam may be such a person. Long-term hospitalization with a serious focus on rehabilitation may be an appropriate answer for such a person, but it may not be the only alternative. In some states, long-term hospitalization for the purpose of rehabilitation is no longer considered an appropriate use of the hospital. As hospitals have been downsized, their per diem costs have risen, so that in most communities long-term hospitalization for the purpose of rehabilitation is simply too expensive. Skilled nursing facilities, although inappropriate, are often the only alternative.

My colleagues and I have suggested the concept of the SAFER house (+4). The acronym stands for Secure Adult Facilities to Ensure Recovery. The SAFER house was proposed to fill a perceived "gap between the active medical treatment provided in a hospital and the intensive treatment and rehabilitation provided in the most aggressive community-based treatment settings" (+4). In Ohio, where I practice, the department of mental health has only recently acknowledged the need for this level of service (+5) and has yet to create such programs. SAFER houses could be on state hospital campuses or in houses in the community. It might be argued that a community-based house will make eventual success in that community more likely (+6).

For Sam to begin a meaningful recovery, he needs intensive, aggressive, and somewhat intrusive treatment and rehabilitation. In our resource-poor community mental health systems, at a minimum this approach would mean a trial of assertive community treatment with state-of-the-art pharmacotherapy. Perhaps the professionals in Sam's system of care need to rethink interminable psychotherapy and reallocate resources to ensure adequate availability of assertive community treatment. If people who, like Sam, are in the most intractable situations are to be helped, communities should consider developing long-term secure residential treatment programs, whether hospital based or community based, with the goal of promoting meaningful recovery for individuals who are unable to recover on their own.

Dr. Munetz is chief clinical officer of the Summit County Alcohol, Drug Addiction, and Mental Health Services Board, 100 West Cedar Street, Suite 300, Akron, Ohio 44307, and professor of psychiatry at Northeastern Ohio Universities College of Medicine in Rootstown (e-mail, mmunetz@neoucom.edu).