The Case of Sam

In Reply: Drs. Moffic and Kuehn make many important and valid observations about what should be in place for an effective community-based mental health system. As they note, these elements include the following:

• An accountable system of treatment and care

• Clear and measurable treatment goals

• Meaningful choices for persons being served that they can meaningfully make

• Fewer intermediaries using funds that could otherwise be employed for direct services

• Residential programs that are less isolated and better integrated into a community

• Effective substituted judgment processes for persons who are incapable of making informed decisions for themselves

• Medication trials that closely monitor side effects and optimize compliance

• Community mental health centers that treat appropriately targeted populations of persons who have chronic, severe mental illnesses

• Improved care and treatment at a lower cost

The challenge for us remains how to achieve these ends. In the case of Sam, the system providing care and treatment sees all these objectives as its aims. It falls short, as does every system that currently exists. All too often a program description does not actually describe a program in practice. Compromises in the model are as frequent as adherence to the model. In some instances, the compromises reflect appropriate flexibility. In others, they are the result of bastardization of the model, a lack of resources, or personnel problems.

We have begun to demonstrate the possibilities of effective, humane, compassionate care and treatment in communities of many types. Ahead of us are the tasks of not allowing our definitions of "community" to be narrowed, improving effectiveness and accountability, and not just settling for care but striving for true habilitation, rehabilitation, and treatment.

Perhaps a banner for our efforts, one that Drs. Moffic and Kuehn could endorse, is "A job half done is a good beginning."