OBJECTIVE: In a multisite study, the authors examined the construct validity and utility of a brief self-report Satisfaction With Life scale, an expanded 21-item version of one of the earliest measures of subjective satisfaction with life used with individuals with serious and persistent mental illness. The Satisfaction With Life scale measures satisfaction in four domains: living situation, social relationships, work, and self and present life. METHODS: Satisfaction With Life scale data were gathered from consumers receiving community treatment at two sites in Los Angeles (N=166 and N=172, respectively) and one in Wisconsin (N=146). A confirmatory factor analysis of a hypothesized four-factor structure using data from the pooled Los Angeles samples revealed that several items were less than optimal indicators of the underlying domain. On the basis of an analysis of each item, the Satisfaction With Life scale was reduced to 18 items, and the factor structure and factor loadings of the revised scale were cross-validated with data from the Wisconsin sample. The 18-item scale was further validated by testing hypotheses regarding the relationship between the instrument's four domains, or subscales, and clinically important life conditions of clients in the areas of symptoms, living and employment situations, and social relationships. RESULTS: The findings provided excellent support for the construct validity of the 18-item Satisfaction With Life scale, which assesses an individual's subjective satisfaction with his or her current life in the four domains: living situation, social relationships, work, and self and present life. CONCLUSIONS: The brief, easily completed 18-item Satisfaction With Life scale is a useful tool in evaluation research for assessing the subjective satisfaction with life of adults with serious mental illness.

This study used data from the long-term experimental evaluation of the Program of Assertive Community Treatment (PACT) to examine the clinical and situational contributors to social functioning in people with schizophrenia. Subjects were 87 young adults with schizophrenia spectrum disorders. Data from two time points, 6 months apart, were used to test models predicting five social outcomes (network size, network reciprocity, sociosexual contact, satisfaction with social relationships, and loneliness) from positive symptoms, work involvement, living situation, and residential mobility. Results indicated that (1) work involvement was associated with larger network sizes over a 6-month period; (2) experiencing an increase in positive symptoms over a 6-month period was associated with the loss of reciprocal network ties, a lessening of satisfaction with social relationships, and an increase in loneliness; and (3) neither living situation nor moving frequently was associated with later social outcomes. These findings suggest strong support for the role of short-term changes in positive symptoms and modest support for the role of work involvement in social outcome.

Back to table of contents Previous article Next article LettersFull AccessA Critique of the Effectiveness of Assertive Community TreatmentMary Ann Test, Ph.D., and Leonard I. Stein, M.D.Mary Ann TestSearch for more papers by this author, Ph.D., and Leonard I. SteinSearch for more papers by this author, M.D.Published Online:1 Oct 2001https://doi.org/10.1176/appi.ps.52.10.1396AboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail In Reply: As codevelopers of the assertive community treatment model, we believe it is important to clarify several issues raised by Dr. Gomory in his letter, in which he contends that it is premature to move assertive community treatment into standard practice as discussed in the article by Ms. Phillips and her colleagues. These authors asked us if we wished to respond to the letter from Dr. Gomory.Dr. Gomory calls for further discussion of issues such as "the therapeutic value of the coercion on which assertive community treatment is based." The assertive community treatment approach never was, and is not now, based on coercion. Quite the opposite is the case. We developed assertive community treatment in the 1970s on the basis of our belief that persons suffering from even very disabling mental illnesses can live freely in the community and experience a satisfying quality of life if they receive adequate supports and assistance (1). Other community treatment efforts at that time were failing because the system was highly fragmented and providers demanded that even very ill clients visit offices or program settings to receive services.Assertive community treatment focused on service delivery mechanisms such as a single integrated team and use of outreach to deliver services, supports, and rehabilitation to maximize the possibility that even the most disabled consumers would remain in the community and have a decent quality of life. Our own conclusion from the literature, when we consider the most rigorous studies and the programs that have high fidelity to the model, is that assertive community treatment is successful in reaching these goals. The willingness to deliver services to clients should not be equated with coercion. Coercion is not part of the model, and if programs that call themselves assertive community treatment programs appear to be using coercion, they should be closely scrutinized and modified.Meanwhile, we believe it is fair to say that many of our earlier efforts were overly paternalistic. Although we differed with many in that era in that we espoused the rights and abilities of persons with severe mental illness to live in the community—indeed, in the same settings as other citizens (2), we shared the prevailing view that staff "knew best" what clients needed. Hence our treatment plans were typically staff derived. Fortunately, the courageous voices of consumers, along with years of experience, have led us to see the enormous strengths of persons with mental illness. The assertive community treatment model has evolved into one of ongoing collaboration with consumers in making and reviewing decisions about goals and methods. The model will continue to improve only when we work in partnership with consumers.Dr. Gomory also points to the shortage of evidence about the effects of assertive community treatment beyond the well-documented reductions in hospitalization, and he accurately notes that we have not yet published data on psychosocial outcomes from a long-term study of assertive community treatment whose early (two-year) findings on hospitalization were reported in 1991 (3). Progress on this study for a number of years was substantially slowed, partly because of the need for the principal investigator (MAT) to assume family caregiving responsibilities and also by the need to devote all resources to the continued collection of the long-term data. Data analyses and writing are now our primary focus, and readers can be assured that all dimensions of the findings will be published as soon as this work is completed.Dr. Test is professor in the School of Social Work and affiliate professor in the department of psychiatry at the University of Madison, Wisconsin. Dr. Stein is professor emeritus of psychiatry at the University of Wisconsin, Madison, Medical School and director of research and education at the Mental Health Center of Dane County, Inc., in Madison.References1. Stein LI, Test MA: Alternative to mental hospital treatment: I. conceptual model, treatment program, and clinical evaluation. Archives of General Psychiatry 37:392-397, 1980Crossref, Medline, Google Scholar2. Test MA, Stein LI: Special living arrangements: a model for decision-making. Hospital and Community Psychiatry 28:608-610, 1977Abstract, Google Scholar3. Test MA, Knoedler WH, Allness DJ, et al: Long-term community care through an assertive continuous treatment team, in Advances in Neuropsychiatry and Psychopharmacology, vol 1, Schizophrenia Research. Edited by Tamminga CA, Schulz SC. New York, Raven, 1991Google Scholar FiguresReferencesCited byDetailsCited byInnovation and Its Discontents: Pathways and Barriers in the Diffusion of Assertive Community Treatment4 November 2019 | The Milbank Quarterly, Vol. 97, No. 4Association Between Hospitalization and Delivery of Assisted Outpatient Treatment With and Without Assertive Community TreatmentMark R. Munetz, M.D., Christian Ritter, Ph.D., Jennifer L. S. Teller, Ph.D., Natalie Bonfine, Ph.D.4 June 2019 | Psychiatric Services, Vol. 70, No. 9A Randomized Controlled Trial of the Rochester Forensic Assertive Community Treatment ModelJ. Steven Lamberti, M.D., Robert L. Weisman, D.O., Catherine Cerulli, J.D., Ph.D., Geoffrey C. Williams, M.D., Ph.D., David B. Jacobowitz, B.S., M.A., Kim T. Mueser, Ph.D., Patricia D. Marks, J.D., Robert L. Strawderman, Sc.D., Donald Harrington, M.S., Tara A. Lamberti, B.A., Eric D. Caine, M.D.1 June 2017 | Psychiatric Services, Vol. 68, No. 10BMC Psychiatry, Vol. 10, No. 1Community Mental Health Journal, Vol. 45, No. 1Journal of Social Distress and the Homeless, Vol. 19, No. 1-2Social Service Review, Vol. 80, No. 3Current Opinion in Psychiatry, Vol. 15, No. 5 Volume 52Issue 10 October 2001Pages 1396-1397 Metrics History Published online 1 October 2001 Published in print 1 October 2001

Back to table of contents Previous article Next article Book ReviewFull AccessThe Strengths Model: Case Management With People Suffering From Severe and Persistent Mental IllnessMary Ann Test, Ph.D.Mary Ann TestSearch for more papers by this author, Ph.D.Published Online:1 Nov 1999https://doi.org/10.1176/ps.50.11.1502AboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail In an era when terms such as "strengths," "empowerment," and "recovery" are beginning to pervade the rhetoric, yet only superficially the practice, of those working with persons with severe and persistent mental illness, The Strengths Model is an essential and rewarding read for staff and trainees of all disciplines who assist these individuals. It is a well-written, thought-provoking volume that explicates in great detail one approach to putting these emerging principles into daily practice. Whether or not one decides to implement the exact strengths model detailed here, which has been developed, refined, and implemented by Charles Rapp and his colleagues at the University of Kansas School of Social Welfare over the past 15 years, the book is likely to open one's mind to radically different ways of doing things in daily work with both clients and their communities.The strengths model as Rapp conceptualizes it is not simply an "add strengths and stir" attachment to existing pathology- or problem-focused paradigms. Rather, it is a real paradigm shift to a strengths and resilience focus that "allows for new and creative ways to work with clients that honor their skills, competencies, and talents as opposed to their deficits."The book begins with a history and critique of the "dominance of deficits" in both the orientation of societies and the foundations of the helping professions, then presents the theory, principles, and research results of the strengths model. The guts of the book follow—that is, detailed chapters on each step in the implementation of the model: the engagement phase, strengths assessment, creating the personal plan, and resource acquisition. The chapters are nicely organized, highly useful practice-methods pieces that provide a wealth of how-to details about content, process, and style, with use of brief but incisive clinical vignettes for illustration.Interestingly, as the author notes, several of the highlighted practice methods—such as assertive outreach, assisting clients in normalized rather than segregated settings, and "one-team integrated services" rather than service brokerage—are similar to those of other effective models such as assertive community treatment. Yet the strengths model stands alone with its virtual total focus on strengths, with almost no attention paid to the illness or symptoms. Indeed, the book would be improved by more direct explication about how the model does deal with these issues and how the psychiatrist best collaborates with this total "strengths approach," as these are frequently asked questions.Potential readers should not be put off by this shortcoming, however, as the strengths model is not antipsychiatry, nor does it deny that mental illnesses are biologically based and result in serious problems and much pain. Rather, it proposes that a radical shift of illness to the background and strengths to the foreground is the most effective path to recovery. Indeed, many consumers have recently been telling us the same thing! The Strengths Model focuses our attention on this possibility and serves as an exceptionally fine, detailed practice manual for how such an approach can be implemented.Dr. Test is professor in the School of Social Work at the University of Wisconsin- Madison.by Charles A. Rapp, Ph.D.; New York City, Oxford University Press, 1998, 224 pages, $36.95 FiguresReferencesCited byDetailsCited byNone Volume 50Issue 11 November 1999Pages 1502-1503 Metrics History Published online 1 November 1999 Published in print 1 November 1999

Lifetime rates of depression are distinctly higher in women reflecting both real and artefactual influences. Most prevalence studies quantifying a female preponderance have examined severity-based diagnostic groups such as major depression or dysthymia. We examined gender differences across three depressive sub-type conditions using four differing measures to determine whether any gender differences emerge more from severity or symptom prevalence, reflect nuances of the particular measure, or whether depressive sub-type is influential.A large clinical sample was recruited. Patients completed two severity-weighted depression measures: the Depression in the Medically Ill 10 (DMI-10) and Quick Inventory of Depressive Symptoms-Self-Report (QIDS-SR) and two measures weighting symptoms and illness correlates of melancholic and non-melancholic depressive disorders - the Severity of Depressive Symptoms (SDS) and Sydney Melancholia Prototype Index (SMPI). Analyses were undertaken of three diagnostic groups comprising those with unipolar melancholic, unipolar non-melancholic and bipolar depressive conditions.Women in the two unipolar groups scored only marginally (and non-significantly) higher than men on the depression severity measures. Women in the bipolar depression group, did however, score significantly higher than men on depression severity. On measures weighted to assessing melancholic and non-melancholic symptoms, there were relatively few gender differences identified in the melancholic and non-melancholic sub-sets, while more gender differences were quantified in the bipolar sub-set. The symptoms most commonly and consistently differentiating by gender were those assessing appetite/weight change and psychomotor disturbance.Our analyses of several measures and the minimal differentiation of depressive symptoms and symptom severity argues against any female preponderance in unipolar depression being contributed to distinctly by these depression rating measures. Our analyses indicated that gender had minimal if any impact on depression severity estimates. Gender differences in depressive symptoms and severity were more distinctive in bipolar patients, a finding seemingly not previously identified or reported.The study had considerable power reflecting large sample sizes and thus risks assigning significant differences where none truly exist, although we repeated analyses after controlling for the type I error rate.

The systematic assessment of subjective experience independently from its impact on schizophrenic's behavior is neglected in most structured interviews and symptom rating scales. However, subjective complaints may predict outcome functioning, medication compliance, and future psychotic episodes and better reflects patients' well-being than does behavioral assessment. We demonstrate the reliability of the Subjective Deficit Syndrome Scale and the considerable prevalence of subjective complaints in 166 acute and chronic inpatients and outpatients. Complaints were correlated with global measures of psychopathology in acute but not chronic patients. They were not correlated with negative symptoms or neurological side effects. Some overlap was observed with measures of depression, although most patients denied depressed mood. We conclude that subjective deficits are prevalent in schizophrenia, that they can be reliably assessed, and that they constitute and independent, clinically important dimension of the disease.

Gender differences were studied in the lives of 122 young adults (mean age = 23.11 years) with schizophrenia or schizophrenia-related disorders who are participants in a long-term study of progressive community care. Across the first 2 years, males who required hospitalization showed a trend toward greater recidivism and spent more time in institutions than women who required hospitalization. Women spent more time in inpatient medical settings for nonpsychiatric reasons. In community living domains, significant gender differences were found in parent roles, frequency of heterosexual relationships and behaviors, substance use, arrest rates, the number who spent time in jail, and residential settings. In the study to date, more males than females have committed suicide. We discuss specific ways in which treatment can be sensitive to these gender-relevant issues. We also note the need for future research on gender differences in schizophrenia to consider the very different community lives of men and women.

This article reports the analysis of prospectively gathered data on eight young adults who committed suicide during an ongoing longitudinal study of long-term treatment of schizophrenia in the community. Young adult men with an early onset of psychiatric illness were identified as a high-risk subgroup. At the time of admission to the study, the subjects who eventually committed suicide reported significantly more distress and tended to be less satisfied with their lives than the other subjects. Specifically, baseline measures of self-reported subjective distress were consistently predictive of later suicide, whereas interviewer-rated measures and postbaseline assessments were not.

Use of nonprescribed mood altering substances is pervasive and problematic in young adults with serious mental illnesses in community care. Fifty-eight percent of young adult clients with clearly defined schizophrenia or schizophrenia-related disorders participating in a long-term community treatment study were rated by staff or themselves as using alcohol, cannabis, or other street drugs several times a week or more. We interviewed in depth a random sample of these "significant users" to obtain their perspective on their frequencies, patterns, histories, contributing factors to, and effects of substance use and their related treatment experiences. Results revealed these clients' substance use to be of long duration and deeply entrenched, with current use often involving multiple substances including both street drugs and substances of "everyday life" (e.g., caffeine, nicotine). Clients reported compelling reasons for use including anxiety reduction, relief of boredom, and a means for social contact. Staff and clients clearly view substance use quite differently, with the latter focusing at least as much on consequences of symptom relief as symptom exacerbation. Treatment implications are discussed.

This chapter traces the beginnings, growth, dissemination, and replications of the Training in Community Living model from the early 1970s to the present.

The Training in Community Living project has been a model program in the state of Wisconsin. It set in motion the development of a statewide community support initiative.

The authors describe the characteristics of 100 young adults with schizophrenia or schizophrenia-related disorders who are being treated in the community, patients who are at high risk for serious, long-term impairment but have not necessarily developed such impairment yet. In contrast to subjects in some other studies of young adult chronic patients, the patients show great variability in previous levels of functioning, such as employment history, ability to live independently, and drug use. The authors hypothesize that highly individualized assessment and comprehensive treatment provided early in the course of illness can prevent or limit chronic functional disability for many patients; they provide recommendations for such treatment.

The clinical research unit from which the Training in Community Living model came is now investigating long-term use of the model in the treatment of young adults with schizophrenic disorders.

To the Editor.— Stein, Test, and Weisbrod (Archives1980;37:392-397, 400-405, 409-412) are to be congratulated on their series of reports comparing traditional hospital-type treatment with community treatment. The "Economic Benefit-Cost Analysis" (pp 400-405) is particularly pertinent. About six years ago, when we closed a large state hospital and established community programs with the available resources, we tried to "follow the dollars" as well as follow-up the patients, but we were finally defeated by the seemingly endless number of variables involved. The authors come close to capturing all these variables. However, when talking about money, mental health administrators have to talk to government officials. Although the authors do make it clear that their analysis is not a "government-budget benefit-cost analysis," the use of their study with state executives or legislators could lead to problems. When these budget people are told that community programs either save money or, at least, break even

This paper reviews research on the community treatment of the chronically mentally ill, in order to determine what services are necessary for deinstitutionalization to succeed with this population. Residential services, assistance in meeting basic needs, crisis intervention services, somatic therapies, problem‐solving outpatient contacts, and comprehensive psychosocial treatments are found to be necessary in order to achieve a number of commonly cited goals in the treatment of the chronically mentally ill. Furthermore, the way that services are delivered may be of equal importance to what services are made available. To be effective services must be delivered in a highly individualized manner, be made assertively available, be structured to maximize the provision of continuity of care, and be provided in an ongoing rather than time‐limited fashion. While clearly more services are needed than currently exist for the chronically mentally ill, it is suggested that treatment can be improved by altering the way in which existing services are delivered to this population.