How Evidence-Based Practices
Contribute to Community Integration
Gary R. Bond, Ph.D.
Michelle P. Salyers, Ph.D.
Angela L. Rollins, Ph.D.
Charles A. Rapp, Ph.D.
Anthony M. Zipple, Sc.D.
ABSTRACT: Since the groundbreaking work of the Robert Wood Johnson Conference
in 1998 identifying six evidence-based practices (EBPs) for people with severe mental
illness (SMI), the mental health field has moved in the direction of re-examination and
redesign of service systems. Surprisingly, one area that has not been fully explicated is
the role that EBPs play in promoting community integration. In this paper, we explain
how community integration is a unifying concept providing direction and vision for
community mental health for people with SMI. As one crucial aspect of the recovery
process, community integration clarifies the link between EBPs and recovery. We
propose an alternate view, grounded in the empirical literature, to the assertion by
Anthony, Rogers, and Farkas [2003, Community Mental Health Journal, 39, 101–114]
that ‘‘EBP research has rarely demonstrated a positive impact on recovery related
Gary R. Bond and Michelle P. Salyers are affiliated with the Department of Psychology, Indiana
University-Purdue University Indianapolis and are also affiliated with the ACT Center of Indiana.
Angela L. Rollins and Anthony M. Zipple are affiliated with Thresholds in Chicago.
Charles A. Rapp is affiliated with the School of Social Welfare, University of Kansas.
Address correspondence to Gary R. Bond, Ph.D., Department of Psychology, Indiana University-
Purdue University, Indianapolis, 402 N. Blackford St., LD 124, Indianapolis, IN 46202-3275;
Community Mental Health Journal, Vol. 40, No. 6, December 2004 (? 2004)
? 2004 Springer Science+Business Media, Inc.
Although the concept of evidence-based practice (EBP) is new to the
field of mental health, its impact already has been felt widely through
federal, state, and local mental health agencies (Hyde, Falls, Morris, &
Schoenwald, 2003). As with any new concept, it has been interpreted in
many different ways. Some have embraced EBPs with gusto; others
have viewed the EBP movement as a threat. One particular perspective
has been that EBPs do not promote recovery-oriented outcomes. In this
paper, we provide a perspective suggesting quite the opposite, that
EBPs are intimately linked to recovery. Our perspective centers on
community integration, which we see as a unifying concept providing
direction and vision in community mental health for people with severe
mental illness (SMI).
The paper is divided into five sections. First, we define community
integration and explain its relationship to the recovery process, pro-
viding a brief historical overview of the emergence of the construct of
community integration in community mental health. Second, we dis-
cuss the current realities for most people with SMI. Third, we describe
the EBP movement. In the final two sections we describe how specific
EBPs contribute to community integration and discuss some criticisms
DEFINITION OF COMMUNITY INTEGRATION
AND ITS RELATIONSHIP TO RECOVERY
Community Integration entails helping consumers to move out of pa-
tient roles, treatment centers, segregated housing arrangements, and
work enclaves, and enabling them to move toward independence, ill-
ness self-management, and normal adult roles in community settings
(Carling, 1995; Nelson, Lord, & Ochocka, 2001). Like others with long-
term illnesses, individuals with SMI want to manage their own lives
and to participate in and contribute to the life of their families and
communities. To use an old-fashioned term, community integration
implies ‘‘normalization’’ (Wolfensberger & Tullman, 1982), that is, the
circumstance in which individuals with disabilities live, work, play,
and lead their daily lives without distinction from and with the same
opportunities as individuals without disabilities. One way to describe
community integration is by stating what it is not: Community inte-
gration is not immersion in worlds created by and managed by mental
570Community Mental Health Journal
health professionals, such as day treatment programs, sheltered
workshops, group homes, and segregated educational programs. These
settings are designed specifically to pull consumers into treatment and
away from community life. The acid test in determining if community
integration is realized is whether consumers are being steered toward a
protected setting that is not part of the ‘‘regular’’ community.
Community integration epitomizes the aspirations of the consumer
movement and, in our view, constitutes one of the two core elements
of the recovery process. Recovery has been defined as both a process
and an outcome (Deegan, 1999; Onken, Dumont, Ridgway, Dornan, &
Ralph, 2002; Ralph, 2000). As a construct, it goes beyond community
integration by incorporating an individual’s self-perceptions and
psychological states, such as hope, pursuit of personal goals, self-
efficacy, and self-determination. Recovery is an intensely personal
journey; it is not a linear progression but consists of periods of growth
and setbacks (Strauss, Hafez, Lieberman, & Harding, 1985). Currently,
there are no standardized methods for measuring the construct of
recovery, although a number of promising approaches have been
developed (Ralph, 2000).
We conceptualize community integration as the external, concrete
manifestation (viewable to the outside world) of the recovery experi-
ence, thus lending itself more easily to empirical measurement. It in-
cludes a set of constructs for which objective proxy measures (as well
as associated subjective measures) have been validated, to a far greater
extent than is currently true for the broader construct of recovery. For
example, in the area of work, a recovery goal for many consumers is
competitive employment that is congruent with personal preferences
and is personally satisfying. These three elements—competitive
employment (Drake, McHugo, Becker, Anthony, & Clark, 1996), match
with personal preferences (Becker, Drake, Farabaugh, & Bond, 1996),
and job satisfaction (Resnick & Bond, 2001)—have been operationally
defined and measured, although this is not to say that other aspects of
community integration in this domain do not warrant more psycho-
The degree to which community integration results in the subjective
experience of recovery is an important empirical question. The litera-
ture on first person accounts of the experience of mental illness is re-
plete with personal testimonials supporting this linkage (Rogers, 1995;
Steele & Berman, 2001). Some empirical studies also suggest that
community integration leads to greater self-confidence, hopefulness,
self-determination, and other facets of the recovery experience (Bond,
Gary R. Bond, Ph.D., et al.571
et al., 2001; Carlson, Eichler, Huff, & Rapp, 2003). A national research
study also concluded that what we are calling community integration
often facilitates recovery (Onken et al., 2002). The opposite process also
occurs; spirituality, hopefulness, and self-determination translate into
action and lead to greater integration, especially when consumers have
supporters who believe in them (Onken et al., 2002). More complete
answers to questions regarding mechanisms of change await the
development of standardized recovery measures.
Historical Context for the Community Integration Construct
Carling (1995) traces the movement toward community integration to
the broader disability and civil rights movements. In the 1960s, the
Civil Rights Movement began advocating for the rights of all individ-
uals to have full citizenship in their communities. Similarly, the pas-
sage of the Community Mental Health Act of 1963 was based on the
optimism that former residents of state psychiatric institutions could
find meaningful restoration of their lives back ‘‘in the community,’’ with
the help of local mental health clinics (Torrey, 2001). The reality fell far
short of the intentions of the legislation, in part because of a poorly
articulated vision of what that integration would look like (Cutler,
Bevilacqua, & McFarland, 2003). The ‘‘reform movement’’ exemplified
by the Community Support Program (Turner & TenHoor, 1978) pro-
vided an appropriate set of conditions for community living, but not
necessarily community integration. All too often, Community Support
Program services replaced the community rather than supporting
community integration. For example, prevocational programs were
surrogates for real jobs; group homes and mental health center-owned
apartments replaced normal tenancy; recreation was dominated by day
treatment-sponsored affairs; transportation services were set up by
mental health centers. Community integration involves being of the
community and not just physically located in the community.
Another impetus toward community integration derived from the
1999 Supreme Court ruling in Olmstead v. L.C., which underscored the
fact that many people with SMI were unnecessarily segregated in
institutions when community living would be possible if the proper
supports were in place. Similar goals were expressed in the Rehabili-
tation Act Amendments of 1992, which aimed at assisting individuals
with disabilities ‘‘to live independently; enjoy self-determination; make
choices; contribute to society; pursue meaningful careers; and enjoy full
inclusion and integration in the economic, political, social, cultural, and
572 Community Mental Health Journal
educational mainstream of American society.’’ Finally, the New Free-
dom Initiative (2003) echoed these same themes of full citizenship,
guaranteeing individuals with mental illness equal access to societal
and environmental resources, equal access to options and opportuni-
ties, and equal ‘‘location of life;’’ that is, places where people live, work,
play, and pray, are the same regardless of the presence of mental ill-
ness (Ralph, 2000).
CURRENT REALITIES FOR PEOPLE WITH SMI
Mental health consumers generally have the same aspirations as the
rest of the population: meaningful work, decent housing, friendships,
health, financial security, and a high quality of life (Carling, 1995;
Rogers, Walsh, Masotta, & Danley, 1991; Steinwachs, Kasper, &
Skinner, 1992). Many consumers today have achieved better lives than
they would have during the era of institutionalization. However, the
reality for most consumers is that genuine community integration
remains an unrealized promise. Some estimates are that less than one-
third are living independently, while about one-third of the homeless
population have mental illness (Torrey, 2001). Many have been ‘‘tran-
sinstitutionalized,’’ from psychiatric hospitals to nursing homes and
other supervised residences (Geller, 2000). Among those consumers
counted as ‘‘living in the community’’ are many who are leading lonely,
isolated, barren lives, often without social or recreational outlets
(Carling, 1995; Segal & Aviram, 1978; Wong & Solomon, 2002).
Studies of incarceration and victimization further document the grim
realities of severe mental illness. Of the 1.1 million individuals held in
state and federal prisons in 1995, the one-year prevalence rates were 5%
for schizophrenia, 6% for bipolar disorder, and 9% for major depression
(SAMHSA, 1997). An estimated 284,000 (16%) of those incarcerated in
American prisons and jails on any given day were people with SMI
(Ditton, 1999). Consumers are also at great risk of being victims of vio-
lence and crime. Between 43 and 81% report some type of victimization
over their lifetime (Rosenberg et al., 2001), and one-third report severe
physical or sexual assault in the past year (Goodman et al., 2001).
Employment and access to education are also challenges for people
with SMI. Over 85% of persons with SMI are unemployed, despite
compelling evidence that most want to work (McQuilken et al., 2003)
and are capable of working in competitive employment, nearly
always preferring competitive employment over sheltered work (Bedell,
Gary R. Bond, Ph.D., et al.573
Draving, Parrish, Gervey, & Guastadisegni, 1998). Unfortunately,
consumer surveys often find that assistance with employment is a
major unmet need, largely unrecognized by practitioners (Crane-Ross,
Roth, & Lauber, 2000; Noble, Honberg, Hall, & Flynn, 1997), perhaps
because they often misjudge consumers as ‘‘unmotivated’’ (Braitman
et al., 1995).
Similarly, consumers who have educational aspirations have often
been discouraged from pursuing such goals, because they have been
seen as ‘‘unrealistic’’ (Shepherd, 1993). As competitive employment
goals gradually have become more accepted, it has become increasingly
apparent that consumers are profoundly disadvantaged in terms of
educational achievements required to pursue meaningful careers
(Unger, 1998). Many consumers have had their educational process
interrupted by the onset of their illness, often limiting immediate
employment prospects to entry-level jobs.
Another area in which community integration is compromised in-
volves substance use disorders, which are estimated to affect as many
as 50% of people with mental illness (Regier et al., 1990). Dual diag-
nosis of SMI and substance use disorder has consistently been associ-
ated with many other negative outcomes, including increased relapses
and hospitalizations, housing instability and homelessness, incarcera-
tion, violence, and economic burden on the family (Drake, et al., 2001).
Four decades after the passage of the Community Mental Health Act,
community integration remains an unrealized goal. A recent large
national survey again confirmed that consumers are poor, relying on
public funding for income; they lack access to affordable, appropriate
housing; job discrimination remains a problem; and psychiatric dis-
ability is often criminalized (Hall, Graf, Fitzpatrick, Lane, & Birkel,
2003). Compounding this set of problems are others that are related
specifically to the mental health services available in most communi-
ties. These barriers to community integration include stigmatizing
attitudes of practitioners, segregated services, fragmentation of
services, and lack of access to services.
In their contacts with mental health centers, consumers often experi-
ence ‘‘spirit-breaking’’ messages reflecting low expectations regarding
their potential to realize their dreams (Prince & Prince, 2002). Mir-
roring prejudices of the general community, many practitioners believe
that independent living is beyond the ability of many consumers.
574 Community Mental Health Journal
Education of practitioners in the principles of recovery is sorely needed
if consumers are to receive respectful, compassionate, and effective
Mental health centers continue to offer contained and controlled ser-
vices that promote stabilization and caretaking at the cost of integra-
tion, self-determination, and empowerment. Emblematic of this
problem is the widespread use of day treatment (Parker & Knoll, 1990).
Despite the espousal of rehabilitative goals, day treatment does not
help people move out of treatment settings and into normal adult roles
in the community. In fact, day treatment services can be discontinued
and successfully replaced with supported employment and other ser-
vices that achieve greater involvement in community life (Bond, 2004).
Fragmentation of Services
Nearly everywhere, consumers are faced with a confusing, fragmented
system of care in which they must go to different programs or agencies
for rehabilitation, mental health, and substance abuse treatment ser-
vices, typically with little co-ordination between providers (New Free-
dom Commission on Mental Health, 2003). Research has made it clear
that rehabilitation programs cannot be effective in isolation from
mental health treatment (Drake, Becker, Bond, & Mueser, 2003;
Mueser, Noordsy, Drake, & Fox, 2003).
Access to Services
Several studies have documented the fact that consumers have prob-
lems accessing services meeting even minimal standards of care
(Lehman, Steinwachs, & PORT Co-Investigators, 1998). Access to high
quality services is even more tenuous. One recent national survey of
3000 consumers found that few had access to EBPs (Hall et al., 2003).
Among those who did receive these services, the majority rated the
access as fair or poor.
What should the response be to this gloomy picture? Despite the great
disparity between the ideal of community integration and the current
Gary R. Bond, Ph.D., et al.575
realities, we have reason to be optimistic. Public support for com-
munity integration is strong (even if public budgets do not reflect this
support). Within the mental health community we have consensus on
what the goals should be, and we have the practices and tools to make
these changes possible. Most importantly, we know much more about
effective service delivery than at any time in the past. As demon-
strated over the past decade, there are several reasons for optimism:
(1) Emergence of EBPs, (2) Emerging knowledge base on how to
effectively train and consult with agencies to implement and support
these practices, (3) Increasing expertise and knowledge based on
involving consumers and family members, and (4) Growing under-
standing of the critical importance of providing mental health, voca-
tional rehabilitation, and substance abuse services by integrated
teams of providers.
THE EVIDENCE-BASED PRACTICE MOVEMENT
AND COMMUNITY MENTAL HEALTH
Emergence of EBPs
Over the past two decades, we have witnessed amazing strides in the
development of effective service models for people with SMI (Drake,
Green, Mueser, & Goldman, 2003). Until recently, the mental health
field lacked consensus on the identification of specific types of EBP.
However, this situation significantly changed in 1998, when a national
consensus panel of leading mental health treatment and services
researchers, consumers, family advocates, clinicians, and administra-
tors identified six practices for adults with psychiatric disabilities
attaining the status of EBP (Mueser, Torrey, Lynde, Singer, & Drake,
2003). These six practices are: (1) supported employment, (2) assertive
community treatment (ACT), (3) illness management and recovery, (4)
family psychoeducation, (5) integrated dual disorders treatment, and
(6) medication management according to protocol. All of these practices
aim at increasing community integration and promoting maximum
social and economic independence.
EBP in mental health is part of a larger evidence-based medicine
movement, which quickly has become a dominating influence in medi-
cine. One Medline search found 12,298 hits to the term ‘‘evidence-based
medicine’’ between 1996 and 2003, with only 2 hits for the preceding
4 years (Flaum, 2003). Following the model of evidence-based medicine,
576 Community Mental Health Journal
EBPs are founded on the meta-principles of (1) using the best available
evidence, (2) individualization, (3) incorporating patients’ preferences,
& Torrey, 2003).
Emerging Knowledge Base on How to Effectively Train and Consult
with Agencies to Implement and Support these Practices
The National EBP Project is a large-scale project to study and improve
strategies for implementing the aforementioned EBPs (Drake, et al.,
2001). The first phase of the project was to create toolkits providing
practical, hands-on material to enable agencies to implement these
practices with high quality. The second phase, now in progress, incor-
porates systematic consultation and technical assistance to help 55
agencies in 8 states to develop environments that will sustain the
practice over time, for example by identifying funding strategies or
fostering stakeholder involvement.
One major pitfall in numerous efforts to develop services aimed at
increasing community integration has been the failure to implement
programs according to the principles defining each EBP (Goldman
et al., 2001). In the last decade, we have begun developing manage-
ment tools to help programs implement practices with ‘‘high fidelity,’’
that is, implementing them as intended. Fidelity scales measuring
quality of implementation have emerged as one such management tool
for establishing and monitoring high-fidelity programs and for suc-
cessful dissemination of EBPs on a broad scale (Bond, Evans, Salyers,
Williams, & Kim, 2000).
Increasing Expertise and Knowledge Based on Involving Consumers
and Family Members in Adoption of EBPs
Many different efforts are under way to increase consumer and family
involvement in developing, monitoring, and disseminating EBPs and
emerging practices. For example, NAMI and other organizations are
offering programs where consumers and families serve as providers of
training (e.g., NAMI’s Peer-to-Peer, Family-to-Family, and Provider
Education programs) (Burland, 1998). Some sites within the National
EBP project have involved consumers and family members as trainers
and as members of ‘‘leadership teams’’ directing the implementation of
Gary R. Bond, Ph.D., et al.577
Growing Understanding of the Critical Importance of Providing Mental
One key barrier to community integration is that traditional mental
health services have focused narrowly on addressing symptoms and
problems, rather than looking at the consumer as a whole person with a
variety of treatment and rehabilitation needs. The resulting service
systems are then brokered, and the consumer is left to navigate the
mental health, vocational, and substance abuse service systems on
their own. EBPs address this problem by integrating a range of com-
prehensive services ‘‘under one roof.’’
HOW SPECIFIC EBPs CONTRIBUTE TO COMMUNITY
? Supported employment helps consumers find meaningful jobs that fit
their preferences, promoting the integration of consumers in the
competitive job market (Bond, 2004). Supported employment avoids
preparatory work activities common in mental heath settings and,
instead, moves consumers through a rapid job search and placement
process, based on their job preferences. Consumers are provided
intensive support in their job search and job placements on a long-
term basis, with integration of both vocational and mental health
services for better outcomes.
? Assertive community treatment is a treatment especially suited for
consumers who have not done well in usual mental health services. It
has been particularly effective in reducing hospitalizations and
homelessness (Bond, Drake, Mueser, & Latimer, 2001). ACT uses a
multidisciplinary team approach to case management with shared
caseloads and frequent staff meetings, intensive community-based
services, and a focus on assistance with daily living skills that helps
consumers maximize their independence and level of functioning in
the community. ACT has a strong focus on helping consumers attain
(Witheridge, 1990), as described below.
? Illness management and recovery embodies the principle of self-
determination and is based on the value that when consumers are in
charge of their own lives and provided the means necessary to make
informed choices, they will make better decisions than if they are
a supportedhousing approach
578 Community Mental Health Journal
directed by medical personnel to ‘‘comply’’ with a treatment plan
(Mueser et al., 2002). Through illness management, consumers learn
to proactively address illness issues such as symptoms, medications,
worries about relapse, and depression, so that they can better pursue
recovery goals, such as employment, creative activities, and friend-
? Family psychoeducation is a systematic approach to educating fami-
lies about mental illness and recovery (Dixon et al., 2001). Family
members also have too often been excluded from the recovery pro-
cess, despite the fact that they are frequently the primary caregivers.
Inclusion of family members as part of the treatment team enhances
the effectiveness of other EBPs and reduces family burden (McFar-
lane et al., 2000; Mueser et al., 2002).
? Integrated dual disorders treatment uses a stagewise approach
to engaging and helping individuals with dual disorders (Drake,
Essock et al., 2001). Rather than parallel treatment for mental
health and addictions, consumers receive intensive, coordinated
community-based mental health and substance abuse treatment on
an integrated team. Practitioners ensure access to housing,
employment and other services often denied individuals with sub-
stance use problems.
? Medication management according to protocol is an approach to
medication use that stresses informed consumer choice, systematic
monitoring of outcomes and side effects, and the use of the atypical
antipsychotics as first-line treatments for schizophrenia (Mellman
et al., 2001). With active collaboration between prescribers and
consumers, medications can play a critical role in community inte-
gration by decreasing symptoms and relapse.
In addition to these 6 EBPs, several emerging practices are critical to
community integration. These are practices that have not yet achieved
a sufficient level of research evidence to justify the label of evidence-
based practice, but are practices that the best evidence to date suggest
contribute to community integration. These include practices that ad-
dress basic needs that are essential to ensure full participation of
consumers in community life. Two such critical practices are supported
housing and supported education.
? Supported housing, first defined in the 1980s (Ridgway & Zipple,
1990), is an approach in which consumers rent or lease independent,
affordable housing that is integrated into the community (i.e.,
Gary R. Bond, Ph.D., et al. 579
separate from the mental health service agency and no live-in staff).
Consumers have access to 24-hour services to avoid crises that might
interrupt housing (Rog, 2004). Significantly, the supported housing
approach has been identified as a core strategy for realizing the goal
of community integration (Wong & Solomon, 2002). The residential
research literature for individuals with psychiatric disabilities is
enormous, and the supported housing paradigm is widely recognized
as the most promising, although much work is still needed in this
area (Newman, 2001; Rog, 2004).
? Supported education refers to a set of strategies for helping con-
sumers pursue post-secondary education (Mowbray, 2000; Unger,
1998). Like supported employment, supported education provides
practical methods for assisting individuals renew their quest to
better themselves that may have been lost with the onset of their
illness. Although a recent review identified 14 quantitative studies of
supported education (Carlson et al., 2003), this literature lacks
methodological rigor. These preliminary studies suggest that sup-
ported education interventions that focus on in vivo assistance while
avoiding segregated classroom preparation may ultimately prove to
be the most effective strategy.
CRITICISMS OF EVIDENCE-BASED PRACTICES
The criticisms of the EBP movement have been strong and widespread
(Essock et al., 2003). They have included many valid and thoughtful
critiques exposing deficiencies in the basic conceptualization as well as
criticisms of specific EBPs.
Regarding the basic conceptualization, one key issue is how EBPs are
identified in the first place. We should be vigilant to the danger that the
process for selecting which practices are ‘‘official’’ EBPs can become
politicized (Mueser, submitted). It is beyond the scope of this paper to
examine the complex issues concerning the methods and criteria for
identifying EBPs (Beutler, 2000). However, differentiating between
‘‘evidence-based’’ and ‘‘emerging’’ practices centers primarily on the
rigor of the research designs used to evaluate effectiveness. In fact,
even among the EBPs identified by the RWJ conference there are dif-
fering levels of empirical support; three practices (supported employ-
ment, ACT, and family psychoeducation) have strong and convincing
evidence for effectiveness, whereas the evidence is weaker for the
remaining three. In our view, however, it is not helpful to dilute the
580 Community Mental Health Journal
concept of EBP to include any ‘‘best practice,’’ if that latter term is
broadened to clinical opinion or popular practices that have not been
exposed to rigorous empirical study (Hughes & Weinstein, 1997). Our
reasoning is simply that if popular practices did in fact promote
community integration, then we would not expect to find the dismal
realities for consumers described above.
Another valid concern is the relationship of EBPs to the consumer
movement and particularly to consumer-run alternatives (Frese,
Stanley, Kress, & Vogel-Scibilia, 2001; Tracy, 2003). Given that
consumer-run services do not have a strong empirical base, some con-
sumers fear that the hard-won financial support for consumer-run
programs obtained over the past decade will erode with the growth of
the EBP movement. Consumers often mention peer support as a critical
factor facilitating their recovery (Onken et al., 2002). We agree with
Tracy (2003) that consumer-run services and evidence-based services
are complementary. Funding for both should be given high priority,
while professionally-led practices lacking an evidence base should be
called on to justify their continued funding. An analysis of where dol-
lars are spent for mental health services would help clarify this dis-
Regarding criticisms of specific practices, ACT has been a lightening
rod for criticism, having been characterized as paternalistic and coer-
cive (Dennis & Monahan, 1996; Fisher & Ahern, 2000; Gomory, 2001;
Williamson, 2002). If being closely associated with the medical model
means that ACT is paternalistic and coercive, then certainly ACT
stands guilty as accused. However, as noted above, evidence-based
medicine provides an entirely different vision for health care. More-
over, numerous reviews suggest that ACT increases stable community
living and that ACT consumers are more satisfied with ACT services
than are consumers receiving traditional case management services.
Some studies also have found improved quality of life for ACT
consumers (Bond, Drake et al., 2001).
The oft-repeated criticisms regarding coercion on ACT teams have
been largely anecdotal; only a few studies have directly surveyed ACT
consumers regarding their perceptions of services (Williamson, 2002).
Some of the criticisms of ACT may be more correctly characterized as
criticisms of poorly implemented ACT teams (McGrew, Wilson, & Bond,
2002). However, it should also be acknowledged that some ACT teams,
especially those specializing in homelessness, jail diversion, or co-
occurring substance use, have extensively used legal mechanisms such
as outpatient commitment and representative payeeship (Gold Award,
Gary R. Bond, Ph.D., et al.581
2001). Legal mechanisms are perceived as coercive among consumers
who are non-adherent to treatment, though apparently not by con-
sumers who are actively participating in treatment (Elbogen, Swanson,
& Swartz, 2003). Clearly, these issues need to be brought out in the
open and studied carefully (Compton et al., 2003; Dennis & Monahan,
1996; Rain, Steadman, & Robbins, 2003).
In addition to many thoughtful and valid criticisms of EBPs, there
are also some criticisms that are based on misconceptions or distortions
of the empirical literature. One of the most troubling is the oft-repeated
insinuation that EBPs have been developed without an understanding
of recovery, or worse, that the goals of EBPs might be indifferent, or
even antithetic, to recovery (Anthony, Rogers, & Farkas, 2003). In our
view, arguments asserting this position distort the EBP literature
while defining recovery in vague, unattainable terms, which no re-
search to date could have measured.
What would recovery look like without community integration? In
some contexts, recovery and community integration are different
ways of talking about the same thing. We agree with Anthony et al.
(2003) that EBP research should measure ‘‘...meaningful roles in
society (e.g., valued work, decent housing, membership in a com-
munity, enrollment in school)’’ (p. 105), but these are precisely what
we mean by community integration. The notion that ‘‘Simple
dichotomous counts of employment or hospitalization are an enor-
mous conceptual distance from what might be described as recovery
outcomes’’ (p. 105) may leave the impression that EBP studies are
reductionistic, whereas ‘‘recovery-oriented’’ studies use richer mea-
sures. If we use Anthony et al.’s standard of avoiding simple counts,
then one could equally question some of the widely-cited findings of
one of the seminal recovery studies (Harding, Brooks, Ashikaga,
Strauss, & Breier, 1987). In fact, competitive employment rates and
other such indicators do tell us a great deal about the recovery vi-
sion of a mental health center, resonating strongly in the attitudes of
practitioners, consumers, and family members (Gowdy, Carlson, &
Rapp, 2003). It is profoundly short-sighted to disparage such simple
Anthony et al. (2003) make a second point regarding the importance
of qualitative methods. We wholeheartedly agree that these are vital to
the advancement of the field and should be included to give a full pic-
ture of outcome. In fact, many excellent qualitative studies have been
conducted on EBPs (e.g., Alverson, Alverson, & Drake, 2000; Angell,
2003; Gowdy et al., 2003).
582 Community Mental Health Journal
Anthony et al. (2003) also state that ‘‘EBP research has rarely dem-
onstrated a positive impact on recovery related outcomes,’’ citing
examples of recovery-oriented measures such as quality of life, self-
esteem, empowerment, satisfaction, and well being (p. 106). We do not
agree: Many studies have shown EBPs to positively impact these
areas. More to the point, however, is the fact that it is generally hard
to show strong experimental effects for these kinds of self-report
measures regardless of what intervention is being studied. In our
opinion, the problem rests more with the difficulty measuring sub-
jective outcomes than with the intervention being measured. To our
knowledge, there is no corpus of non-EBP research showing experi-
mental effects for any of these measures, nor do Anthony et al. (2003)
offer such evidence.
Community integration is a unifying, standardized, and measurable
set of concepts for the assessment of EBPs. It provides a focus to link
our scientific methods to our value system and capture the essential
goal of EBPs in way that may sidestep what we believe to be a false
dichotomy between EBPs and recovery. The purported lack of direct
evidence that EBPs promote recovery can be largely attributed to the
lack of standardized measures of recovery. To the extent that recovery
has been measured at all in existing studies, it refers to measures
such as functioning in satisfying adult roles, quality of life, and self-
esteem. As valid and more precise measures of recovery are devel-
oped, they should be included in evaluations of evidence-based and
Each of the aforementioned EBPs and emerging practices goes be-
yond maintaining consumers ‘‘in the community,’’ but strives toward
truly integrating them into the economic, political, and social spheres of
society. Not all areas of community life are adequately covered by the
established EBPs. Social integration, involving reciprocal relationships
between consumers and others in society, has not been adequately
achieved (Angell, 2003; Prince & Prince, 2002). Certainly, more work
also is needed in the areas of jail diversion, treatment for medical
conditions, and treatment for trauma and co-occurring post-traumatic
Consumer choice and self-determination also are fundamental char-
acteristics of EBP. In contrast to traditional vocational approaches,
Gary R. Bond, Ph.D., et al.583
ACT teams enable individuals to find safe, affordable housing in the
community. Integrated dual disorders treatment uses motivational
strategies to respect the individual’s goals and stage of recovery. All of
the EBPs focus on consumers’ personal goals as the starting point for
Beyond the debate regarding which practices should be deemed
evidence-based is our assumption that widespread acceptance of a
reasonable set of EBPs is far superior than having no evidence-based
framework at all, even if the list is incomplete. It is clear that EBPs
will evolve over time as we learn more. In the meantime, an evidence-
based framework has helped to clarify and organize planning at the
federal, state, and local levels. By defining what does work, it has
made the continuation of unproven service models less easy to
maintain. Judging from its rapid acceptance in medicine, it seems
unlikely that the EBP tidal wave will recede in mental health, despite
Practices emphasizing community integration have consistently
proven to be more effective than clinic-based, segregated approaches,
whether we are discussing employment, academic attainment, resi-
dential alternatives, or skills training. Community integration is part
of the fabric of EBP.
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