Tracing the Tensions, Constructions, and Social Relations Surrounding Community Integration Practice for Individuals with Severe Mental Illness: A Focus on Assertive Community Treatment
Horgan, Salinda Anne
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ABSTRACT Assertive Community Treatment (ACT) is considered the primary service-delivery vehicle for integrating individuals with severe mental illness into the community. Research on the model suggests that it has been helpful in aiding service users to achieve basic levels of integration including stabilized housing and maintaining financial and social security (Bond, Drake, Mueser & Latimer, 2001; Mueser, Bond, & Drake, 2001). However, critics of the model emphasize its limited success in enabling higher-order aspects of integration such as mainstream employment, recreation and socialization (Estroff, 1981; Gomory, 1998, 2001, 2002a, 2002b). These are fundamental criticisms given the significant investment in the model by policy makers. The rationale for the failure to promote higher-order integration typically rests on two central assumptions: a) service users are incapable of realizing full integration; and b) practitioners lack the training, skills, and philosophical base required to foster full integration. By focusing on the personal and professional characteristics of practitioners and service users, these views serve to obscure organizing structures operating at organizational, systemic, and social levels that encourage common ways of thinking about and carrying out community integration practice. The concern of this thesis is to explicate the impact of these organizing structures on the everyday practices engaged in by individual practitioners. In particular this thesis focuses on how practice becomes shaped by external structures that overrule both personal and professional values and intentions. The current study used the method of institutional ethnography to examine the impact of organizing structures of ACT in shaping how community integration practice is conceptualized, carried out, and accounted for on an everyday basis. The study findings are threefold. First, they suggest that organizing structures foster goals associated with protection as opposed to empowerment. Second, they reveal that organizing structures advance an individual-level focus over a social-level focus, prohibiting the community capacity building and environmental change necessary for fostering social autonomy and empowerment. Third, they show that organizing structures encourage practices discordant with integration, resulting in contradictory and therefore inconsistent attempts to facilitate higher-order aspects of integration. The power of these organizing structures is such that the personal and professional intentions of providers to facilitate broad community integration are consistently overruled within the context of everyday practice. The results of this study highlight the powerful role played by organizing structures in shaping community integration practice and provide an important theoretical model for planning, implementing, and evaluating models of service delivery for individuals with severe mental illness.