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Continue shopping. Item s unavailable for purchase. In such a system, rehabilitative services may not even be offered as a service option. However, ignoring these services in policy making at the national and state levels will result in missed opportunities for moving the mental health system toward more humane and cost-effective long-term solutions.
Effectively balancing appropriations within a service system implies taking into account not just the service system design and the characteristics of the target population, but their evolution over time. Longitudinal studies of serious mental illnesses have indicated that the functional deterioration and deficit symptoms underlying chronicity may originate in the early years of the disorder 88 and that reduction in clinical needs over the life cycle is possible if patients receive rehabilitative and support services early in the illness 14 , 15 , Although additional research is certainly needed, these findings suggest an age-specific vulnerability to external stresses that can be modified by appropriately timed rehabilitative interventions.
Because the external circumstances and stressors that influence relapse and heavy service utilization ebb and flow in unpredictable ways, the service system must continue to evolve to compensate for such random or insufficiently understood fluctuations. As findings about the relationship between resource shifts and functional improvement of the target population accumulate, the service system can more effectively anticipate and respond to the factors that generate relapse.
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Consideration of balanced appropriation in a community support system implies a vision of deinstitutionalization, like recovery itself 9 , 89 , as a dynamic process, with an evolving knowledge base that continues to revise and extend the vision. Now that long-term institutional care is no longer the central focus of the service delivery system, policy makers can shift their attention to the consequences of deinstitutionalization within the community.
For example, the nursing home reforms that were initiated by the Omnibus Budget Reconciliation Act of OBRA were a response to the fact that many persons with psychiatric disabilities who had formerly resided in state psychiatric hospitals had been transinstitutionalized to nursing homes and other long-term-care facilities. Despite the beneficial consequences of OBRA, many still reside in those settings 90 , Now that rehabilitative techniques have been developed and proven effective, the vision of deinstitutionalization can be broadened to include a move away from acute services and structured residential settings toward independent living, employment, and improved quality of life.
This phase of deinstitutionalization requires a shift in future resource allocation toward rehabilitation. However, if savings due to improved utilization management are diverted to other uses, such as corporate profits or government cost shifts, rather than following the client, the potential systemic gains will be undermined. Although the literature on the effectiveness of psychosocial rehabilitation is convincing, a limitation is that the published studies have examined intervention strategies individually rather than in combination.
Consequently, we do not know which combinations and amounts of interventions produce optimal effects for which subjects, nor do we know what the additive population effects might be. For example, individual differences in capacity and responsiveness to currently available treatments have been shown to vary considerably 92 , 93 , and individual differences in prior treatment and current medication usually have not been analyzed.
In addition, studies of supported employment interventions have shown high dropout rates of 41 to 77 percent within six months, but they have not identified client characteristics that predict success or failure other than prior work history.