General introduction 11 moving away from the use of large, centralized mental institutions toward community-based care for individuals with mental illness (18). In the 1960s and 1970s, the civil rights movement fostered deinstitutionalization. Reports of frequent coercive interventions in hospitals influenced public opinion and led to the closure of psychiatric hospitals. In addition, outpatient treatment and drug therapy were cheaper than hospital care (19). However, deinstitutionalization in the United States occurred too rapidly. Sufficient alternatives to hospitalization were not available. Because many psychiatric patients lacked family ties and experience with independent living, many ended up homeless or in community-based sheltered care such as halfway houses, family care homes, board-and-care homes, nursing homes, or even jail (20, 21). The quality of these homes varied widely (18). Sometimes, there were calls for a new asylum (19). After deinstitutionalization, there was a great need for high-quality outpatient services. In the mid-1970s, in response to this need, the concept of a Community Support System (CSS) emerged. A CSS refers to “a coordinated network of persons, services and provisions organized at a regional level, in which persons with SMI themselves take part and which provides many different means of support in their attempts to take part in the community”(8, 22, 23). Relevant CSS components include rehabilitation services, housing, family and community support, peer support, mental health treatment, and crisis response services (8). For social integration, other important functions of CSS are learning self-management, including coping skills, social skills training, connecting with people at meeting places, practical assistance such as income support, and educating the public to overcome stigma (22). The United States as a trendsetter for innovations in community care It appeared that central government-imposed deinstitutionalization initially led to many challenges in the United States but also in other countries such as the United Kingdom (24) and Italy (25). However, especially in the United States, it encouraged creative innovations to CSSs. In the late 20th century, various care innovation projects emerged to provide adequate community mental health care to people with SMI (26). Inspired by these American models, many innovations were implemented in the Netherlands. Initially, in addition to supportive housing (27, 28), case management played a central role (7, 29-31). For the substitution of psychiatric hospitals, day hospitals were introduced (32-34). To provide relevant daily activities, club-houses (35-38) and supportive employment projects were started (39).
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