Rehab Rounds : Replicating Effective Supported Employment Models for Adults With Psychiatric Disabilities

Introduction by the column editors:Many barriers must be overcome for the successful dissemination and adoption of model programs in mental health (1). Generally, the more complex and demanding of resources the model program is, the more obstacles are encountered in its effective "transplantation." Some facilities or agencies simply lack the fertile fields required by resource-rich model programs. For example, the Program for Assertive Community Treatment (PACT) requires a staff-to-patient ratio of one to 20 or less. Few mental health agencies can afford that level of staffing.Another obstacle to successful dissemination is the resistance of staff at the receiving site to adopt a new model that might be philosophically incongruent with their previous approach to clients. One example is Maudsley Hospital's attempt to implement the home-based, PACT model of service delivery in a poor section of London (2). Even at this resource-rich, academic hospital—the premier psychiatric hospital for training and research in the United Kingdom—the model ultimately failed because the Maudsley Hospital staff clamped down on the autonomy of the community-based team after a PACT consumer murdered a baby and the tragedy received national media attention. The hospital and community-based team returned to the more traditional, hospital-based service philosophy with audits and utilization review tightly controlled by the hospital.Similarly, the introduction of the PACT model has failed in some state systems in the United States where staff have been reluctant to shift their professional roles toward mobile, outreach, and in vivo activities, even when the state's top management endorsed the model program.In this month's Rehab Rounds column, Neil Meisler and Olivia Williams describe the trials and tribulations of mounting two model programs—PACT and Individual Placement and Support (IPS) —for seriously mentally ill consumers in a rural mental health center in South Carolina. The authors describe how the individuals responsible for adopting these model programs had to make many compromises, leading to a common feature of successful adoption of innovations— "reinvention" of the model program to fit the unique constraints, resources, limitations, and staffing available in the host setting (3).