The care of people with chronic mental illness has been a significant concern of the mental health system over the past three decades. The deinstitutionalization movement led to tremendous changes in the locus of treatment for people with chronic mental illness. Between 1955 and 1981 the population of state mental hospitals decreased by almost four-fifths from a high of 558,922 in 1955 to a low of about 126,359 in 1981 (Segal, 1987). In 1955 three of every four persons receiving mental health care were treated as inpatients; presently the situation is reversed, with three of four persons receiving mental health care being treated as outpatients.
By the mid-1970s, there was much concern expressed about the problems of deinstitutionalization: increased stresses on families caused by patients' returning home to live, often without adequate community-based services; the continuing high admission rates to mental hospitals and escalating readmission rates; inadequacies of community care; lack of coordination between hospital and community-based services; lack of management systems to ensure adequacy and appropriateness of patient placement; inappropriate institutional placements (for example, nursing homes) for many patients; and the lack of coordination, planning, and priority setting on the national and state levels to address the needs of this population group. For many people with chronic mental illness, deinstitutionalization has meant being "dumped" into communities to live in single-room occupancy hotels, boarding homes, or apartments, often without adequate necessities of life and needed daily living supports (Group for the Advancement of Psychiatry, 1978; President's Commission on Mental Health, 1978; U.S. General Accounting Office, 1977).
GOVERNMENT SUPPORT FOR SOCIAL NETWORKS
In an attempt to address these issues at the federal level, in 1977 the National Institute of Mental Health (Turner & TenHoor, 1978) developed the Community Support Program (CSP) as a model for providers of comprehensive, community-based services for people with chronic mental illness. The NIMH also made grants available to enable states to implement the model. The CSP is based on the premise that individuals with chronic mental illness need more than mental health services. To live successfully in the community, they also require non-mental health services such as assistance with daily living skills, housing, employment, socialization, finances, and medical care.
The comprehensive service delivery approach of the CSP includes an emphasis on enhancing the social support systems of individuals with chronic mental illness. The conceptual model was based on theory and research indicating that the client's social network, in conjunction with a network of services, could help people with chronic mental illness adapt to community living (Tessler & Goldman, 1982). A major thrust of this approach is to create a "network of caring" through a comprehensive system of case identification, outreach services, assistance in applying for entitlements, crisis-stabilization services, psychosocial rehabilitation, sheltered living arrangements, medical and mental health care, and backup support to family and friends. The CSP includes a focus on enhancing social supports by providing opportunities for people with mental illness to develop social skills and leisure activities as part of psychosocial rehabilitation (Turner & TenHoor, 1978).
A central component of the CSP is the provision of case management services designed to directly address a major criticism of deinstitutionalization--that clients face a large, diverse, fragmented, and uncoordinated system of services that they often have difficulty negotiating on their own. The importance of case management to the social work profession is highlighted by a number of articles and books on this topic (Gerhart, 1990; Johnson & Rubin, 1983; Kanter, 1987; Rapp, 1992; Rapp & Chamberlain, 1985; Rose, 1992; Rothman, 1992). …