Anyone reading this case study would agree that the community mental health system has failed Sam. Some may conclude that the only option is long-term hospitalization, but there we would differ. The real solution is to understand where the system has failed in Sam's case and to make it work. We can accomplish this quite simply by involving Sam in this process rather than treating him as an unfeeling object. In this way we can develop a workable treatment plan to replace the one that has not been effective.

Sam's clinical profile is not atypical for an adult served by a public mental health authority. The questions posed are confronted regularly by inpatient and community practitioners, case managers, and policy makers. However, they are not the most germane to understanding Sam and to having a better picture of his clinical and rehabilitative needs. It is only by understanding Sam more clearly that we can determine the most appropriate setting to meet his needs.

From my experience as a social worker and policy maker, I know that psychosocial rehabilitation can be provided in a variety of contexts and that people want to participate in choosing the setting for their rehabilitation. Psychosocial rehabilitation is certainly not the sole domain of public psychiatric hospitals. In fact, inpatient facilities have only recently embraced the concepts of rehabilitation and recovery. If systems adhere to these concepts, then Sam must actively participate in his treatment.

In developing a clinical profile, recitation of a long list of services and medications without a fundamental reevaluation of a person's treatment goals is a common error made by practitioners. When goals are not incorporated into the context of service provision, the discussion often centers on placement rather than on the most appropriate setting to ensure success in meeting treatment goals. In addition, without Sam's participation in the establishment of goals and the creation of a therapeutic alliance, there is little likelihood of long-term success.

Before answering the question of "where," one must first gather some basic information about the "who," "what," and "why." Sam has maintained consistent long-term clinical relationships; however, has he benefited and is he currently benefiting from these relationships? What have these relationships meant to Sam? Does he feel that his own needs, strengths, and concerns have been heard and understood? Do staff convey a sense of hope to Sam?

Because of Sam's deterioration, staff likely feel helpless and hopeless. Viewing a change in setting from the community to a long-term hospitalization as the only available option is a natural consequence of hopelessness. Individuals like Sam challenge us as practitioners and policy makers to learn from our experience of helplessness and to use our network of supervisors and peers to plan a better course, not to act on our frustration. Developing a creative treatment vision that is uncomplicated by frustration or helplessness is a fundamental challenge to the clinical leadership of Sam's treatment team.

One strategy is to fundamentally resurvey the treatment landscape. Because practitioners often feel that they have "given their all" to an individual, an outside consultant may be able to highlight gains that these practitioners may not appreciate and may offer some objectivity in assessment. For instance, review of Sam's medication trials should include duration and dosage. The consultant does not need to be an expert in all areas. Provision of support for the team and reassessment of Sam's treatment plan are often meaningfully accomplished by a respected clinician.

This comprehensive assessment should provide the basis for a new treatment plan and a location for such treatment. However, before deciding on long-term hospitalization, I would investigate whether assertive community treatment might be an appropriate intervention. This program, as described by Dr. Munetz in his discussion of the case, carefully incorporates clinical, rehabilitative, and supportive services into a highly individualized plan.

Sam's difficult 20-year course of illness and the challenges he has presented emphasize the fact that changing policies and systems, such as developing assertive community treatment, and expanding rehabilitation options in the community are ultimately clinical interventions for individuals. As professionals in public mental health systems, we must always be aware of the person, who has hopes, dreams, and aspirations. We must not let the person be solely defined by his illness. It is therefore essential that Sam be empowered to participate in all discussions about his goals and to incorporate these goals into any revised treatment plan. Public mental health systems must be responsive to the needs of individuals and their families at all levels within the organization.

Yet the reality is that for the most part, the services of public mental health systems are not an entitlement in our country. Public services depend on budgetary priorities and appropriations. There are more needs than resources. Having stated the obvious, I will add that it is also incumbent on state mental health systems to ensure that clinical, not fiscal, decisions prevail in individual situations. It is essential that direct care staff and practitioners make sound clinical decisions, incorporating the client in the process. It never ceases to amaze me how creative direct care and clinical staff can be, even when resources are scarce, in mobilizing the resources necessary to meet the needs of a person like Sam.

Commissioners are accountable to the public to ensure that highly responsive mental health services are provided to individuals with serious mental illness in a cost-effective manner. A key task of a commissioner is to create and maintain a work environment that ensures that clinical decisions promoting the concepts of rehabilitation and recovery prevail throughout the system. It is the role of managers and policy makers to reconcile clinical needs with fiscal realities. Within such a context, the needs of an individual like Sam are occasionally brought to my attention. These situations provide me with firsthand information about individual needs and resource constraints. Often I or my leadership team can address an individual's immediate situation. Knowledge of the needs of a client like Sam is important to support future budget requests. My experiences listening to the life stories of people like Sam serve as a powerful reminder that a responsive mental health system is built on a positive alliance among staff and individuals with mental illness to achieve mutual treatment goals and better quality of life.

Ms. Sudders is commissioner of mental health of the Commonwealth of Massachusetts. Send correspondence to her at the Department of Mental Health, 25 Staniford Street, Boston, Massachusetts 02114 (e-mail, marylou.sudders@dmh.state.ma.us).