Innovative Approaches for Difficult-to-Treat Populations

True to its title, this edited collection focuses on creative approaches for special populations of people with mental illness. The first third of the book considers children and their families, including neighborhood-based services, substance abuse services, and community-based treatments for serious juvenile offenders. Another third considers adult populations with severe and persistent mental illness in rural areas, in foster care, with substance abuse, in inpatient and crisis services, in vocational services, and in elder years. The final third of the book integrates the various approaches with an overview of policy issues and ethics.

Henggeler, a children’s specialist, and Santos, with interests in public-sector psychiatry, have combined their talents to explore commonalties across interventions that have been evaluated empirically or that have demonstrated cost-effectiveness. The result is this volume that emphasizes pragmatic, socioecological models, applied in the individual’s natural environment. Although the chapters are uneven in quality, all adhere to the editor' theme so that a progressive structure of the book is evident.

The developments during the past 15 years are exemplified in the Child and Adolescent Service System Program (CASSP) model, which is presented as an ecological alternative to the medical-psychological model and its allegedly more limited focus. The Casey Foundation's influence in redesigning service delivery systems for urban youth through restructuring existing services and emphasizing early intervention and preventive services is documented.

From vivid case studies of rural Program for Assertive Community Treatment (PACT) teams to lists of demonstration projects and contact persons for services to the elderly, the section on adult populations takes a utilitarian approach. Although many professionals may be familiar with PACT and similar models, the chapters can provide a different twist to something you think you already know. The concept that many new programs are hybrids of existing models encourages readers to use the models that are presented to further evolve treatment possibilities.

The authors apply the same pragmatic template to exploring policy-driven systems like Medicaid and statewide mental health systems. They conclude aptly with discussions of values and ethics and encourage an examination of the way program development choices are made. Their point is that most innovative programs with proven effectiveness can be established in other locations with trained staff and reallocation of existing funding.

The major flaw in the volume is that many of the ideas seem curiously dated. Given the rapid financial, theoretical, and information currents in modern mental health care, what is presented no longer seems like innovation but like standard practice. Most articles appear to have been written in 1994 or earlier, contributing to the sense that this is a good history, an exploration of how we got to where we are rather than of where we are going. Nonetheless, the book—valuable for the authors’ theoretical and pragmatic vision of the mental health field—could be useful in teaching students and as a reference for practitioners in the field. Overall, this book is bound to please those looking for a survey of mental health treatment in the U.S. in the 1990s.

Dr. Fenby is deputy area director of the MetroSuburban Area of the Massachusetts Department of Mental Health in Medfield, Massachusetts.