The International Journal of Psychosocial Rehabilitation

Problems with Caring for People with Severe Mental Disorders:
A National Plan of Research to Improve Services
(A Progress Report)

Arthur J. Anderson, Ph.D.

Consulting Clinical Psychologist - Honduras
Adjunct Faculty - Antioch University


 Anderson, A. J. (1997). Problems with 'Caring for People with Severe Mental Disorders - A National Plan'. International Journal of Psychosocial Rehabilitation. 1(1), 47-49.

Abstract: This brief report critiques NIMH's progress in achieving the goals set forth in the NIMH and NAMHC report entitled "Caring for People with Severe Mental Disorders: A National Plan of Research to Improve Services". The national plan is briefly discussed and problematic areas of grant funding and approval processes explored. Recommendations are made as to the selection of investigators and research methodologies to fully achieve the goals set forth in the plan. 

Though mental health program and service research has become a high priority for federal agencies, advances in study methodologies and grant funding mechanisms have lagged far behind and threaten the underlying goals of the mental health reform legislation. Since 1992, research funding has increased from $90 million to $369 million budgeted for the current fiscal year. With the reorganization of ADAMHA (Alcohol Drug Abuse and Mental Health Agency) in 1992, the National Institutes of Mental Health (NIMH), National Institute on Drug Abuse (NIDA), and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) have been congressionally mandated to devote no less than 15% of their total budget for health care services research, all coordinated by NIMH [ADAMHA Reorganization Act, 464R (f)(2)]. Though this increase in funding clearly demonstrates an increased level of commitment by the federal government to improving service research and overall program effectiveness, no provision was made to address how this research process would proceed or how improved service delivery would actually occur.

The NIMH publication entitled Caring for People with Severe Mental Disorders (NIMH, 1991) set forth clear goals for improving mental health services and gaining a better understanding of causes and consequences of mental illness for afflicted individuals, their families, and communities. This document serves as a blueprint for mental health reform by establishing research priorities in the areas of assessment research, characteristics of mentally ill people, treatment modalities and settings, rehabilitation, and outcome research.

The problem with this initiative lies not with the goals or strategies set forth in the plan, but in the implementation by NIMH and associated federal agencies. The research section of this plan noted demonstration research projects, controlled service trials, modeling studies of service systems, and uncharted approaches as viable approaches to gaining a better understanding as to what works for whom under what circumstances. In reality, only the demonstration projects and controlled studies have been applied in a very traditional public health approach to impact evaluation. These approaches typically follow a molecular approach in the investigation of therapeutic effectiveness and cannot produce valid information with which to model future program changes and initiatives in mental health (Anderson, 1997).

Traditional research approaches tend to focus on controlled "SCIENTIFIC" studies. Using correlational, causal comparative and other experimental and quasi-experimental approaches, NIMH sponsored program services studies negate the global effects that treatment programs have on individuals, their families, sponsors and political backers, the so called 'stakeholders' of programs. Studies that do not follow the traditional "SCIENTIFIC' approach are simply not funded by NIMH or associated agencies. Many 'real world' programs and services may not fit into the scientific methodologic mold. Thus, programs that may have tremendous value to their consumers and communities may not be recognized, simply because the methods to study and report on their success are not yet considered 'Good Science'.

In a recent correspondence with NIMH, it was specifically noted that studies that involve politics in mental health programs and studies that are not experimentally (scientifically) valid would not be considered for grant review. This was in spite of the fact that NIMH is now concentrating on studies that involve politically sensitive groups, such as the research for mentally ill women, investigated by women (Hohmann, 1996). Bias in investigators or study subjects can hardly be considered unbiased and nonpolitical. Yet, since this research policy only mandates a funding stream for proposed investigations, it stands as a valid research agenda, while other (not so politically correct) studies remain unfunded. Such funding bias undermines the goals set forth in the national plan.

Another problem with the NIMH application of "Caring for People" lies in the grant application process itself. Encumbered by a resilient bureaucracy within the National Institutes of Health, the grant application process is almost beyond all but professional grant writers. This includes university grant writers and professors who may have never set foot in a mental health program, but who feel free to submit lengthy research proposals that are generally accepted because they follow the format that NIMH likes to see.

To improve the quality of mental health service delivery we should be reaching out to program administrators, clinicians, families, non profit organizations and their funding sources who have actual experience with mental health service delivery to gain information as to what works, for whom, under what circumstances. We should not rely almost solely on the wisdom of the fiscally, politically or academically correct who have little or no actual experience in mental health service delivery. The current grant process is extremely encumbered and geared toward university researchers and is thus bound to fail when real world applications and research strategies are required.

To gain a true and full understanding of what works in services research, patients, families, clinicians, program directors, administrators, and their hospital and/or community sponsors must have an active voice in the research process. Program evaluations that focus on modeling and uncharted approaches should be encouraged into the research funding process. Reforms in the grant approval process should be initiated to ensure that all voices are heard in determining the future of services research. And finally, for this initiative to succeed, innovative applied research approaches that focus on the therapeutic outcomes of treatment programs should be explored by those who work with severely disturbed patients and who have the expertise to actually tell what works and what does not for all patient populations, without regard to their group affiliations or political correctness .


ADAMHA Reorganization Act of 1992, Pub. L. No. 102 321, 464R (f)(2).

Anderson, A. J. (1997). Methodological Approaches in Mental Health Services Research and Program Evaluation. International Journal of Psychosocial Rehabilitation. 1(1).

Hohmann, A. A., & Parron, D. L.(1996) How the new guidelines on inclusion of women and minorities apply: efficacy trails, effectiveness trials, and validity. Journal of Consulting and Clinical Psychology. 64(5), 851-855.

National Institute of Mental Health. (1991). Caring for People With Severe Mental Disorders: A National Plan of Research to Improve Services. In C. A. Traube, D. Mechanic, & A. A. Hohmann, (Eds.) (DHHS Publication No. ADM 91 1762). Washington, DC: U.S. Government Printing Office.

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