Public behavioral health services for adults with serious and persistent mental illness have changed significantly over the past three generations. An individual experiencing the onset of schizophrenia or bi-polar disorder in 1950 could typically expect a lifetime of custodial care in institutional settings. All involved: the patient, her/his family, and her/his treating clinician(s) would have no hope for recovery and no expectation for independent community living. Fifteen years or so after first onset of the disorder, primitive psychotropic medications would become available and the individual could be stabilized, albeit intellectually and emotionally blunted, and subjected to the unpleasant and ultimately disabling side effects of the medications.

Another individual experiencing first onset of serious mental illness in 1970 would have different experiences and expectations. Most likely the individual would cycle repeatedly through psychiatric hospitalizations (on average about 20 days every two years.)³ Between hospitalizations, the individual would face the choice of institutional- type care in congregate residential facilities or living independently (usually with family) and receiving intermittent clinic-based services. There was still no expectation on anyone's part that she/he would live or work independently, or would enjoy friendships and social activities. Medications would have no greater positive benefits, although the techniques for mitigating side effects would be improved. This individual would rarely experience lengthy or lifetime institutional care. Instead, she/he would be confined to a netherworld in which the care and supports supplied by the institution were removed, while no replacement or alternative care and supports were available in most communities.

In early 1990, an individual experiencing first onset of a serious mental illness could have a vastly different experience. For general mental health services (i.e., depression, anxiety, post-traumatic stress, etc.) the combination of new medications and brief cognitive-supportive therapies have proven to be almost universally effective. For individuals with serious mental illness, new atypical anti-psychotic medications were becoming widely available and new community services technology such as assertive community treatment, psychosocial rehabilitation, and supported housing and employment were being proven to be successful. Individuals and their families could see and feel the effects of new brain science and new services approaches; for the first time they could routinely hope for independent living and employment in communities of their choice. Throughout the '80s and early '90s the organized advocacy of families (i.e., National Alliance for Mental Illness [NAMI]) and somewhat later consumers, fostered service improvements and increased public accountability for the quality, responsiveness, and effectiveness of services. They also brought about national awareness of the needs of individuals with serious mental illness.

Some individuals suffering serious mental illness today have benefited greatly from these scientific and service technology advances in public behavioral health care systems. Unfortunately, for a variety of reasons public behavioral health systems throughout the United States have been slow to implement these proven technologies. The result is that the vast majority of low-income individuals with serious mental illness, including those in Arizona, continue to receive services and supports more reminiscent of the 1960s than reflective of the 1990s. The consequence, as well documented in the media, is increased incarcerations, increased homelessness, and increased stress on families and communities.

The preferred public behavioral health system for adults is comprised of a number of interlocking and interdependent elements. These start with basic treatment philosophy and values, and extend to specific face-to-face clinical and community support services. As with the preferred child and family public behavioral health system, the integration and continuity of these components are as important to consumers and families as is the presence of each discrete element.

In Volume I the following key elements of the preferred public behavioral health system for adults have been described:

• Recovery values and principles
• Consumer self-determination and choice
• Continuity of connection with the system
• The Community Support Program (CSP) approach - services and supports for rehabilitation and Recovery
• Psychosocial rehabilitation approaches
• Peer supports/consumer operated services
• Early intervention
• Crisis services
• Mobile outreach/ACT/ACM teams
• Medical and clinical treatment/medication management