Richard H Hunter
Illinois Department of Mental Health and Developmental Disabilities and Southern Illinois University
Patrick W Corrigan
University of Chicago
JEFFREY R. BEDELL received his PhD in clinical psychology from the University of South Florida in 1975. He is currently an associate professor of psychiatry (psychology) at Mount Sinai School of Medicine and is the director of Community Options, a clinical research program at Elmhurst Hospital Center developing and evaluating clinical and cost-effective community treatments for persons with serious mental illness. RICHARD H. HUNTER received his PhD from Southern Illinois University at Carbondale in 1982. He is chief psychologist for the Bureau of Clinical Services, Illinois Department of Mental Health and Developmental Disabilities, and is clinical associate professor in the Department of Psychiatry at Southern Illinois University's School of Medicine. He is working on programs and intervention strategies for treatment-resistant patients and interventions for people with a dual diagnosis of mental retardation and mental illness.
PATRICK W. CORRIGAN , PsyD, is an associate professor of psychiatry at the University of Chicago, where he directs the Center for Psychiatric Rehabilitation, a clinical, research, and training program for persons with serious mental illness and their families. He is also the principal investigator and director of the Illinois Staff Training Institute for Psychiatric Rehabilitation, related to the implementation and maintenance of effective rehabilitation programs in real world settings.
Correspondence may be addressed to Jeffrey R. Bedell, Mount Sinai Services of the Mount Sinai School of Medicine, Elmhurst Hospital Center, 79-01 Broadway, Elmhurst, New York, 11373.
Psychologists increasingly have the opportunity to work with persons with serious and chronic mental illnesses. Managed care encourages services that rely less on hospital treatment and more on a combination of brief and intensive outpatient therapy and long-term, low-cost maintenance and support. Diagnostic practices needed to be effective in such an environment include categorical and functional assessment. Psychological treatments that have been demonstrated effective include cognitive—behavioral social skills training, pragmatic supportive therapy, personal therapy, the multimodal functional model, therapeutic contracting, case management, and multiple family therapy. These innovative assessment and treatment techniques are described along with some experimental treatments of cognitive dysfunction.
In the past, many psychologists believed that they had little to offer individuals suffering from serious mental disorders, such as schizophrenia and chronic major depression, and considered those cases to be more suitable for psychiatric treatment that was based on pharmacology and hospital care. Psychology training generally includes little exposure to course work and practical training with seriously mentally ill individuals ( Millet & Schwebel, 1994 ), and there are relatively few role models in the profession to encourage students to pursue this area of specialization. The mainstream of psychology seems to focus on treatments for less severe psychological problems, on behavioral medicine, and on neuropsychology ( Stewart, Horn, Becker, & Kline, 1993 ).
However, the treatment of persons with serious mental disorders is becoming an increasingly important area of practice for psychologists. There is a small group of psychologists who have focused on this population for many years (e.g., see Wohlford, Myers, & Callan, 1993 ), and they have made important contributions to the treatment, management, and prevention of serious mental illness ( Geczy & Sultenfuss, 1994 ; Hargrove & Spaulding, 1988 ). There has been a significant change in psychology's understanding of the recovery rate from serious mental illness, indicating that most people respond to appropriate treatment and many fully recover (Harding, Zubin, & Strauss, 1987 ). Demonstrating the importance of a changing focus of psychological treatment, the American Psychological Association (APA) recently established in the Practice Directorate a Task Force on Serious Mental Illness/Severe Emotional Disturbance that reports to the Committee for the Advancement of Professional Practice (CAPP). This Task Force focuses on issues of training, treatment, contact with consumers, and psychopharmacology. The Task Force assists the CAPP in providing expertise and leadership to help the profession remain vital in an era when privatization of the public sector and legislation for parity of mental health coverage are focusing increasingly on persons with serious mental disorders ( Staton, 1991 ; Sullivan, 1995 ).
It is increasingly important for psychologists to have assessment and treatment skills suitable for this population of clients. The goal of this article is to describe both the major shifts in practice relevant to persons with serious mental illness and the innovations that have developed in recent years regarding psychological assessment and treatment. Because of space limitations, we can neither present all treatment approaches nor provide an historical review of the precursors of each approach. We do, however, provide detailed information on some of the most widely used and well understood treatments that may be of interest to psychologists.
What are the changes in the practice environment that are shaping clinical psychology? Psychologists today are being asked to provide effective treatment to persons who at one time were considered inappropriate or poor candidates for psychotherapy, and restrictions are being placed on the nature of treatments provided. Patients increasingly have the characteristics outlined below.
The New Practice Environment.
Serious and Chronic Disorders
Psychology, as a profession, has in the past focused on persons with mild and moderate disorders. We psychologists have increasingly had the opportunity to treat persons with serious disorders, such as schizophrenia, schizoaffective disorder, bipolar disorder, delusional depression, and pervasive developmental disorder. Of course, psychologists have provided clinical services for persons with these disorders in the past. However, in the future, clients with these diagnoses may be increasingly prevalent in psychologists' clinical practices. Clients treated in public mental health settings may exclusively have these serious disorders ( Staton, 1991 ; Sullivan, 1995 ).
Not only do clients currently treated in outpatient settings have more serious disorders, but many of them are more acutely symptomatic than were patients treated in outpatient settings in the past. This change is the result of a shift in treatment patterns that requires (a) the presence of more severe symptoms before a client is admitted to inpatient treatment and (b) shorter inpatient stays (perhaps 10 days per year, Staton, 1991 ) that necessitate the discharge of clients with less well stabilized symptoms. As a consequence, more intensive outpatient treatment programs are being established to treat persons with more acute symptoms, both to reduce the need for hospitalization and to facilitate early discharge. The psychologist is expected to use his or her expertise in evaluating and stabilizing symptoms, enhancing coping skills, and maintaining clients in the community. Psychologists are valuable to the treatment process when they have treatment skills relevant to stabilizing clients with acute symptoms and providing skill enhancements. It is also important that the psychologist demonstrate leadership in establishing a network of treatment that mobilizes professional, consumer, and family resources.
Fewer Environmental Supports
Clients with serious disorders are known to have relatively fewer environmental supports than persons with less serious and chronic disorders. Clients who have been symptomatic over a long period of time strain their support system. Families sometimes withdraw and place more reliance on the mental health practitioner. Persons with serious disabilities are less well able to maintain their entitlements. Housing and income may be substandard or inadequate. The psychologist, to be effective, must know how to develop social supports and ensure clients apply for and receive needed entitlements.
It is increasingly shown that persons with serious disorders have multiple disabilities. Substance abuse is the most frequent problem compounding a mental health disability. Mental retardation may co-occur with mental illness, and personality disorders frequently accompany schizophrenia and major depression. In addition, persons with schizophrenia often experience significant levels of anxiety and depression that must be treated in addition to their hallucinations, delusions, and behavioral difficulties.
Clients today offer more challenges to the practitioner. The following make matters even more difficult:
1. Practitioners are required to use less hospital care. In the past, persons with serious disorders who were symptomatic and had poor environmental supports would be readily hospitalized. Hospitalization provides protection for the client and ensures that a skilled multidisciplinary team of professionals is available 24 hours a day. However, at a rate of $500 or more for a day of inpatient treatment and in light of many demonstrations of community-based alternatives to hospitalization, hospital care is increasingly reserved for those who clearly cannot be treated in less restrictive (and less costly) alternatives.
2. Practitioners are also required to provide briefer outpatient therapy. At the same time that inpatient treatment is being restricted for the sickest patients, outpatient therapy will be limited as well. Brief therapies that focus on specific symptoms and functional deficits have become the treatments of choice. Practitioners skilled in effective short-term therapies are in demand.
Managed care is increasingly targeting mental health services to persons with specific categories of mental illness. For example, legislation has increasingly focused funding toward services for persons with serious mental disorders, such as schizophrenia, schizoaffective disorder, bipolar disorder, delusional depression, and pervasive developmental disorder ( Staton, 1991). At the same time, treatment is to be focused on functional disabilities related to these categories of mental illness. For example, treatment of a person with schizophrenia must be focused on variables such as deficits in coping skills, environmental deficits, or family conflicts that directly contribute to the exacerbation of the schizophrenic disorder. Global treatments or those that focus on the process of therapy (e.g., transference) will generally not be supported unless they can be shown to address the patient's diagnostic disorder. Thus, it is essential that the practitioner be skilled in both categorical and functional assessment.
Advances in the Assessment of Persons With Severe Mental Illness
Because treatment is increasingly focused on people with more serious disorders, it is essential that practitioners have skills diagnosing conditions such as schizophrenia, schizoaffective disorder, bipolar disorder, delusional depression, and pervasive developmental disorder. The Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM—IV ; American Psychiatric Association, 1994 ) has become the standard for categorical diagnosis and is accepted by insurance companies, Medicare, and Medicaid. Thus, skill in the use of the DSM—IV is necessary. It is recommended that practitioners learn standardized systems of categorical diagnosis, such as the Structured Clinical Interview for the DSM—IV (SCID—IV; First, Spitzer, Gibbon, & Williams, 1995 ). The empirical training of psychologists prepares them to be excellent diagnosticians, and skills using standardized psychological assessments should ensure the accuracy and reliability of psychologists' categorical diagnoses.
Most managed care companies want the clinician to demonstrate how the treatment provided is related to the categorical disability of the patient. Focusing on functional disabilities is helpful in this regard. For example, a functional assessment of an individual with the categorical diagnosis of schizophrenia may reveal a skill deficit in his or her ability to state requests assertively. This skill deficit is important because it leads to stressful conflicts with family and peers that result in increased symptoms of schizophrenia and relapse. The functional skill deficit may be treated by providing communication skills training for the patient and family. The development of the functional capacity (communication skill) in this patient will have a direct impact on the schizophrenic illness.
Functional assessment focuses on the degree to which the individual's abilities and performance match the demands of his or her home, work, school, family, and social situations. By comparing the functional skills and resources possessed by the individual to those required to maintain community tenure, one gleans information about functional areas of strengths and deficits. Treatment is targeted at deficit areas. Practitioners skilled at functional assessment can provide information essential to guiding the treatment of persons with serious mental disorders. Detailed examples of these types of assessment techniques are provided by Farkas, O'Brien, Cohen, and Anthony (1994) and by Yoman and Edelstein (1994) .
The treatments described in this section illustrate a range of approaches, each with its own procedures and areas of emphasis. They do, however, share a number of common features that tie them together. These commonalities include the following:
Advances in the Treatment of Persons With Severe Mental Illness
1. The treatments share a positive view of the patient. Much has been written about the poor prognosis of persons with serious mental disorders such as schizophrenia. For example, in describing the syndrome of schizophrenia, the DSM—IV states "Complete remission . . . is probably not common . . . some appear to have a relatively stable course . . . others show a progressive worsening associated with severe disability" ( American Psychiatric Association, 1994 , p. 282). Such a view of these patients is overly pessimistic, stigmatizes patients, and discourages treatment. Practitioners of the treatments described in this article have a positive view of patients and treatment. In addition to having clinical experiences, these practitioners are aware of research findings such as those that found up to half of schizophrenic patients significantly recover from their disorder ( Harding et al., 1987 ) and that those who become "chronic" are much helped and improve in response to appropriate treatments ( Bedell, 1994 ). Hopefulness is an essential ingredient in the treatments described in this article.
2. These treatments also share a learning and skill training orientation. Most treatments that have been shown to be effective with persons who have serious mental illness are based in a social learning theory and behavior therapy tradition. This theory and tradition include a positive orientation to treatment that attempts to build patients' self-awareness, awareness of others, and coping skills. Procedures are structured, objective, and standardized whenever possible. They emphasize didactic education, demonstration and modeling, practice, feedback, and in vivo treatment.
3. The treatments share an outcome orientation. The procedures described in this article focus on the goals and outcomes of treatment as well as the process, but they emphasize the former. Objective goals are preferred to subjective ones. If a prescribed treatment process does not result in the desired outcome, the process of treatment is modified in an attempt to obtain the desired outcome.
4. These treatments also mobilize nonprofessional resources. We note that a common theme of many of the following treatments is the use of peers, families, and other nonprofessional persons to enhance treatment outcomes. Nonprofessionals are recognized as being essential partners in treatment, who may be superior to professionals in many important ways. They often know more about the community and its resources, are better able to motivate patients for treatment, function as credible role models of adaptive behavior, can monitor patients' daily well-being, are better able to establish friendships and supportive relationships, and can teach clients unique coping approaches because of their personal experiences.
There are a number of innovative psychological treatments that use these features and have been shown to be effective with persons with serious mental illness. Space does not permit a description of all effective treatments. Rather, a few approaches are presented to provide useful examples of the work being done in this area and to stimulate the creativity of readers. The following section describes an overview model of treatment, referred to as targeted—intermittent long-term therapy . Also, we present specific techniques developed for persons with serious mental illness, such as cognitive—behavioral social skills training, multimodal functional model treatment, therapeutic contracting, case management, multiple family therapy, pragmatic supportive therapy, and personal therapy. Several innovative experimental treatments of cognitive dysfunctions are also presented.
Targeted—Intermittent Long-Term Treatment
How is it possible to provide brief, effective, and economical therapies for clients who have more serious and long-lasting disabilities while minimizing the use of hospital treatment? One answer is to use a model of treatment referred to as targeted—intermittent long-term therapy .
With this type of therapy, treatment is provided very intensively (perhaps daily) during periods of increased symptomatology and functional difficulty by a team of professionals, including a psychologist, psychiatrist, and case worker. The effort and cost of this targeted phase of treatment is high but is justified by the client's risk of hospitalization, which would involve even more effort and cost.
This intensive treatment is only provided intermittently because intensive treatment is not warranted once the client's functioning increases. As the client gains functional stability, the frequency of treatment is reduced from every day to 5 days per week, then to every other day, then to twice per week. As progress continues, direct treatment from the psychologist is reduced to weekly, biweekly, or monthly sessions. The frequency of the professional contact is matched to the client's current needs.
During long periods of stable functioning, treatment may be shifted from the psychologist to a case manager, who may meet with the client on a biweekly or monthly basis. This reduced contact is associated with lower cost, which is appropriate given the functioning level of the client. During these periods of reduced direct contact, learning and rehabilitation continue and the patient's functional status is monitored.
Of central importance is the idea that the therapist is readily available to provide the needed treatment but at the intensity and frequency warranted by the client's functioning level. In addition, the learning that occurs in each acute episode of treatment is used again the next time the client experiences difficulties. Over a long period of time, these targeted—intermittent learning episodes enable the client to develop competence at coping with problems that exacerbate symptoms and place him or her at risk of relapse. This model of treatment may be operationalized in many ways. The types of innovative assessment and treatment practices described in this article are consistent with this model.
Cognitive—Behavioral Social Skills Training
Social skills training is the single most important innovation for the psychological treatment of persons with serious mental illness. As an empirically based approach to treatment, it has, during the last 20 years, evolved into an effective mental health intervention. There are now applications of social skills training to major depression, schizophrenia, and a variety of serious disorders; these applications have been reported in over 100 published evaluations that have been thoroughly reviewed ( Brady, 1984 ; Hersen & Bellack, 1976 ; Ladd & Mize, 1983 ; Morrison & Bellack, 1984 ; Robertson, Richardson, & Youngson, 1984 ; Wallace et al., 1980 ). Most recently, Benton and Schroeder (1990) reported the results of a meta-analysis of 27 well-designed studies evaluating the effectiveness of social skills training for persons with schizophrenia. In their review, these authors only included studies that used controlled designs, clear social skills training methods, and objective outcome measures. Using sophisticated statistical techniques, Beton and Schroeder discovered that research on social skills training reliably showed (a) social skills training yielded significant improvement in assertiveness, anxiety, and other specific behaviors; (b) the social skills learned in therapy generalized to natural, real-life settings; (c) compared to other treatments, social skills training produced superior social functioning, with treatment differences increasing over long periods of time; (d) social skills training resulted in superior hospital discharge rates; (e) social skills training resulted in lower rates of relapse compared to other treatments; and, finally, (f) the superior effects associated with social skills training were the same with schizophrenic samples and those composed of a heterogenous mixture of seriously mentally ill patients.
It is interesting that, although there has been widespread research showing the effectiveness of social skills training, there is little consensus regarding what constitutes an effective training program. In general, it consists of instructions or coaching, live modeling, videotaped modeling, simple rehearsal, role-play rehearsal, verbal feedback, videotaped feedback, interpersonal reinforcement, and homework assignments. The training teaches (a) problem-solving skills (e.g., Bedell & Michael, 1985 ; McFall, 1982 ; Penn et al., 1993 ), (b) communication and assertiveness skills (e.g., Bellack, Morrison, & Mueser, 1989 ; Brown & Carmichael, 1992 ; Wallace, Liberman, MacKain, Eckman, & Blackwell, 1992 ), or (c) both communication and problem-solving skills ( Bedell & Lennox, 1997 ; Hogarty et al., 1986 ; Wallace & Liberman, 1985 ).
It appears that social skills training programs that use a combination of communication and problem-solving skills training yield the most impressive outcomes. For example, research reported by Wallace and Liberman (1985) and by Liberman, Mueser, and Wallace (1986) evaluated the effects of communication and problem-solving skills training for schizophrenic patients living with highly critical families. The treatment evaluated was a 9-week program that emphasized training in various elements of communications skills, including how to attend to relevant social cues, process social information to develop appropriate responses, and make skilled behavioral responses. This skills training focused on effective use of communication to make requests and respond to the requests of others. In addition, clients were taught problem-solving skills that focused on teaching them to generate and evaluate alternative solutions to problems and to choose an effective response. Extremely positive outcomes resulted from this program on a variety of meaningful treatment outcome measures. A trend toward reduced rehospitalization rates was also reported during a 1-year follow-up period.
Hogarty et al. (1986) reported the results of a treatment that similarly used training in communication and problem-solving skills. This treatment additionally established a low-stress environment and provided social support and empathy from staff. Compared to an active control that received socialization and stress management training, this treatment reduced the rehospitalization rates of patients with schizophrenia by nearly 50%. Even better results were obtained when families also learned effective communication skills.
A third study ( Bedell & Ward, 1989 ) evaluated another program of psychological treatment that was based on communication and problem-solving skills training. In this program, skills training was combined with active medication and behavior management techniques ( Ward & Naster, 1991 ). Participants showed a dramatic reduction in length of treatment and showed a significantly reduced rehospitalization rate during most of the 30-month period following discharge. In addition, substantial reductions in the cost of treatment were observed.
Communication and problem-solving skills training has also been used successfully in family therapy. Falloon, McGill, Boyd, and Pederson (1987) described a program of behavioral family therapy that has greatly influenced treatment of families of persons with serious mental disorders. These clinicians provided communication and problem-solving skills training to clients and family members in the home environment, ruling out the necessity for treatment in a clinic or hospital setting. Results revealed improvement in social adjustment and symptoms and a reduction in hospitalization. These empirical findings demonstrate that skills training programs that have combined both communication and problem-solving skills training are remarkably effective for persons with serious mental illness.
Examples of Social Skills Training Groups
Social skills training focusing on problem-solving and communication skills is well suited to a group therapy format. Group therapy provides obvious cost-effective potential by allowing one clinician to simultaneously work with 8—10 clients. This format also increases effectiveness of treatment by capitalizing on the feedback and support provided by peers who participate in the group therapy. There are time-limited and open-ended applications of social skills groups. Time-limited groups are used to stabilize a client by focusing on specific problem areas (symptoms or functional deficits). Open-ended groups, in comparison, provide a long-term, cost-effective way to evaluate and treat relatively stable clients.
A client participates in a time-limited group to achieve a specific set of treatment goals in a specified period of time. Once these goals are accomplished, participation in the group is discontinued. Clients are not maintained in treatments they do not need; thus, the cost-effectiveness of time-limited groups is obvious. Social skills training groups easily fit this format of treatment.
With the program of treatment described by Bedell and Lennox (1997), it is apparent that focused, time-limited groups concentrating on the development of self-awareness of wants and feelings, interpersonal communication, assertiveness, problem-solving skills, and cognitive coping skills may each be presented in 4—6 contact hours. Or, time-limited groups encompassing two or three of these areas may be presented. There are many customized time-limited packages that can be developed to meet the varying needs of clients. The goal of this time-limited approach is to closely match the treatment to the needs of the client and to present it in a focused program of brief duration. Focused and time-limited groups are useful to stabilize a client by focusing on acute symptoms, such as anxiety and functional deficits (e.g., discord with roommates or family members).
An open-ended group is one that has a broad agenda and operates for a long period of time. Clients who complete a time-limited program of skills training, as described in the previous section, often benefit from subsequent participation in an open-ended group. Participation in an open-ended group allows clients to apply the skills learned in the time-limited group to real-life situations over a long period of time while receiving supervision, on-going mental status evaluation, and support. Open-ended groups usually meet with less frequency than time-limited groups to match the needs of the client. A stable client who has developed a good understanding of how to participate in his or her own treatment and who has a functional support network may need to meet only monthly for evaluation and monitoring of progress toward long-term goals. Of course, if problems develop, the frequency and intensity of therapy may be increased. The ability to vary the intensity and frequency of skills training groups adds to the clinical and cost-effectiveness of this approach.
An effective open-ended therapy group for persons with serious mental illness can be organized around a problem-solving format. Such a group focuses on identifying problems, defining them in a solvable form, generating alternative solutions, evaluating the alternatives, selecting an alternative for implementation, and determining the effectiveness of the problem-solving plan. Descriptions of problem-solving groups that are based on this model are available (e.g., Bedell & Lennox, 1997). When conducting a problem-solving group, one should follow a structured format consisting of three distinct segments: socialization, go around, and in-depth problem solving ( Bedell, Provet, & Frank, 1994 ). Each of these components is described below.
A socialization period is used to start a problem-solving group. In a 60-min problem-solving group, 5—10 min are dedicated to socialization(this length is increased to 15 min for a group that meets for 90 min). During this segment, discussion of treatment issues and psychological problems is strongly discouraged. Clients are to practice casual social interaction that, ideally, does not focus on problems. After all, outside the therapy setting, who is going to want to interact with someone who primarily talks about his or her medication and symptoms? The therapist joins in the socializing and facilitates discussion of recent activities or experiences, current news events, and plans for future holidays and social activities. In addition to providing practice in positive social behaviors, the purpose of this activity is to allow members (and the therapist) to become better acquainted with each other by learning about leisure time pursuits, interests, friends, family, acquaintances, and other lifestyle information. This information is helpful in building cohesiveness of the group, providing foundation material for use in problem solving, and, ultimately, developing social support and networking among the group members.
Immediately following the socialization period, a so-called go around is conducted. This activity gets its name from the fact that group members are usually gathered in a circle, and the focus of attention moves from one individual to another around the circle. For each group member, participation in this activity is brief, lasting no more than 5 min, during which he or she provides an update on progress implementing goals from previous meetings and new problems arising since the last meeting.
The go around has several functions. First, it enables the group to follow up on the progress individuals have made dealing with problems addressed in prior group sessions. Follow-up continues on each problem presented to the group until it has been fully resolved or otherwise discontinued. The go around also provides each person the opportunity to briefly present a new problem with which he or she may want the group's help. The group leader conducts an informal mental status screening of each client during the go around, which is followed up after the meeting by an thorough evaluation if a problem is suspected.
Following the go around, the group selects one member's problem for in-depth attention. This problem is reviewed using the complete problem-solving process described in detail elsewhere ( Bedell & Lennox, 1997 ; Bedell et al., 1994). This activity is time consuming and generally occupies the rest of the session. It is extremely rare that more than one problem is given in-depth attention in one group session.
Nationally recognized models of treatment that use social skills training have been developed. The Boston University model of psychiatric rehabilitation (e.g., Farkas et al., 1994) emphasizes (a) diagnosis (setting an overall rehabilitation goal, performing a functional assessment, and assessing resources), (b) treatment planning (planning for skills development, planning for resource development, determining responsibilities, projecting time lines, and monitoring responsibility), and (c) intervention (direct skills teaching, skills programming, resource coordination, and resource modification).
The UCLA (University of California, Los Angeles) version (e.g., Liberman, Mueser, Wallace, Jacobs, Eckman, & Massel, 1986) encompasses assessment, training in personal skills, and modification of living environments in those areas relevant to community life. Areas of training include self-care, medication, and symptom self-management; family relations; peer and friendship relations; vocational and employment pursuits; money management; residential living; recreational activities; transportation; food preparation; and choice and use of public agencies. Their programs encompass two major strategies: helping the person develop or reacquire social and instrumental skills and modifying the person's social environment to become more supportive and to compensate for continuing impairments, disabilities, and handicaps. Also included are behavioral family management and a job club. The former includes education about the nature and management of schizophrenia, training in verbal and nonverbal communication skills, and training and practice in problem-solving skills. The job club is composed of an integrated package of training, support, and management designed to teach job-seeking skills and to sustain the job search.
Individual Psychotherapy Skills training
The concepts of skills training (described previously) and cognitive therapy provide the foundation for individual therapy for persons with serious mental disorders. These applications are practiced widely, although no specific model has been developed and empirically validated. However, the relative objectivity and simplicity of the skills training model allows the client to understand his or her internal processes better and become a more skilled participant in therapy. For example, a client may come to his individual therapy session expressing feelings of sadness and depression. He is helped by learning that these feelings are associated with wants for which he has abandoned hope. The therapy may then be directed to evaluation of the wants and either acceptance of the loss or an increase in skills to enable the individual to pursue what is desired. In a similar manner, the patient with chronic anger is helped to understand that these feelings are associated with desired but unmet wants. Therapy can be directed to evaluating the wants and applying the positive problem-solving process to determine how and if wants can reasonably be met. The anxious patient is guided to understand that his or her feelings imply perception that something bad is expected to happen. Therapy can then be directed to evaluating these expectations, which can lead to their reappraisal or to positive problem solving ( Bedell & Lennox, 1997 ).
A model of cognitive—behavior therapy for persons with schizophrenia has been presented by Kingdon and Turkington (1994) . The main goal of this treatment is to explain and destigmatize confusing and frightening experiences (such as hallucinations and delusions) while not losing sight of the fact that something is seriously wrong. This treatment emphasizes the fact that most, if not all, symptoms of schizophrenia occur in so-called normal individuals under a variety of circumstances but are interpreted as being the result of environmental or stress variables, not a mental disease. Treatment attempts to help the schizophrenic individual conceive of these experiences as potentially an ordinary part of everyday life. Patients are guided to reinterpret these symptoms in such a way as to reduce their importance and, subsequently, the feelings of anxiety, hopelessness, and despair engendered by them.
An excellent example of an expanded application of social skills training to individual psychotherapy for persons with schizophrenia is referred to as personal therapy ( Hogarty et al., 1995 ). This approach uses a multifaceted and long-term approach to individual therapy that (a) takes into consideration the individual's information processing deficits, (b) stages treatment interventions over time to match the functioning level of the client, and (c) focuses on issues of affect dysregulation, defined as the loss of control of mood. First, using modeling, rehearsal, feedback, and homework, the client is taught methods of becoming aware of and understanding his or her feelings and other internal states. Training to develop increased awareness of others follows. A treatment contract is developed that targets variables believed to be related to relapse, such as medication compliance and dosage, drug and alcohol use, and use of coping skills.
The problem-solving model, very popular in social skills training, also provides straightforward guidelines for individual therapy. In fact, individual therapy logically follows a process of first identifying the problem that brings the client to treatment, next clarifying it, then developing various possible solutions, then selecting one for implementation, and, finally, following up on attempts to execute solutions. A problem-solving approach to individual psychotherapy that includes these components has been presented by Nezu, Nezu, and Perri (1989) along with many clinical examples with persons with major depression.
Although research has generally found traditional psychotherapies to be ineffective with persons with serious mental disorders ( Scott & Dixon, 1995b ), there is an indication that some forms of supportive therapy may have promise. Rockland (1993) reviewed the literature and suggested a model of pragmatic supportive therapy that does the following would be effective: strengthens the therapeutic alliance; enacts environmental interventions; provides education, advice, and suggestions; offers encouragement and praise for success; sets limits; strengthens adaptive defenses; and emphasizes strengths and talents. Future research should endeavor to articulate a clear model of pragmatic supportive therapy and compare it to proven models, such as those described previously.
The Multimodal Functional Model
The multimodal functional model (MFM; Gardner & Hunter, 1996 ) demonstrates a psychological intervention for persons with treatment-resistant serious mental illnesses. It involves (a) categorical and functional assessment, (b) cognitive—behavioral intervention, and (c) development of an integrated treatment team, when appropriate. The MFM was designed to address the pervasive problem of inadequate integration of various biomedical and psychosocial diagnoses and interventions and has the following components.
The diagnostic process begins with a specification of the functional deficits and symptoms that require special attention, including, for example, hallucinations, delusions, dysphoric mood, verbal and physical violence, self-injury, property destruction, and extreme uncooperativeness. The symptoms and deficit behaviors are observed and recorded to provide pre-intervention baseline information that guides the development of treatment and also serves as a means of monitoring the impact of the interventions.
These diagnostic data are organized into those playing primary and secondary instigating roles in order to better direct the clinician in developing hypotheses about the functionality of various presenting symptoms. The functions of various medical and psychosocial deficits in initiating and maintaining the target symptoms are highlighted. The relative magnitude of impact (minor, moderate, major) of the various biopsychosocial variables contributing to the instigation and repeated recurrence of target symptoms is articulated.
Implementation and monitoring of interventions
The diagnostic formulations serve as a basis for directing interventions. Supported by objective data, the clinician (prior to implementation) specifies (a) the types and magnitudes of changes in the target symptoms expected from each intervention and (b) the time frame in which these changes can be expected. Specification of this information is valuable because it indicates when ineffective interventions should be terminated and replaced by alternative interventions, thus preventing undue continuation of unsuccessful practices.
Worksheets are provided to guide the practitioner, client, and family through the diagnostic—intervention processes. These worksheets provide a framework for noting instigating influences and other features hypothesized to be related to the problem behavior.
One worksheet provides a framework linking these diagnostic—intervention formulations with an implementation schedule and outcome measures. This framework entails a specification of the staging (timing) of the various interventions along with a description of the changes expected and the time within which these changes should be obtained. Clinical decisions relative to the timing and sequence of implementing various interventions are based on consideration of (a) presumed magnitude of influence, (b) the relative intrusiveness and potential side effects of specific interventions, and (c) the extent to which the effects of any intervention are dependent on the effects of earlier interventions. As the clinical decisions are made, the objective method of measuring impact of each intervention is selected along with the person responsible for data collection and reporting. From this information, another form organizes a summary of the various biomedical and psychosocial interventions into an integrated plan. This integrated summary is an efficient means of representing the multiple diagnostic intervention formulations that comprise a person's current clinical program.
Gardner and Hunter have field-tested this model in consultation and training initiatives with hundreds of clinical staff in several states. These experiences revealed that clinicians representing the range of mental health professionals find this clinical decision model valuable in encouraging the development of a truly integrated set of diagnostic—intervention case formulations and for facilitating ongoing dialogue and cooperative efforts by members of the clinical staff, the client, and the family. Furthermore, it has been found to be especially beneficial in situations where clients have not responded to typical interventions. The MFM fosters a level of understanding of symptoms' contextual and functional features that allows more focused treatments, promotes more adequate measurement of progress and outcomes, and guides clients and staff to reformulate diagnostic hypotheses and alter or replace ineffective interventions. This structured planning and evaluation model leads to enriched service arrays while increasing efficiency by encouraging participants to select those interventions that have a positive impact.
Case example of MFM
Sue was a 47-year-old, single, employed woman who lived with her elderly mother. She had a diagnosis of paranoid schizophrenia and three previous hospitalizations, starting when she was in college. Symptoms included command hallucinations–voices directing her to stab her mother, with commands to "do it now!"–anxiety, and depression. Because of increased frequency and intensity of symptoms, the referring therapists were concerned that she would be hospitalized, something everyone wanted to avoid if possible. Sue's symptoms were partially managed by Risperadal, Klonopin, and Ativan.
The first step of the MFM consultation identified influences that instigated the symptoms. It was determined that Sue's residence was in an unsafe and deteriorated area. The mother refused to move, denying the neighborhood problems. Living in a dangerous neighborhood represented a physical—environmental influencing event that contributed to Sue's symptoms of fear, anxiety, and depression. A psychosocial—environmental influencing event was detected: The mother had a habit of smoking in bed, causing Sue fear that the house would catch fire. Another psychosocial—environmental influence, her inability to discuss her vulnerabilities and concerns with her mother, affected all of Sue's symptoms.
The next step in the MFM consultation was to identify stimulus conditions that would trigger Sue's symptoms. It was found that the most recent exacerbation followed the murder of an 11-year-old boy in Sue's neighborhood. Sue reported that two other hospitalizations were preceded by violent neighborhood crimes to which she strongly reacted. Her fears were worsened by performance of essential daily activities that required her to move about in the community (such as going to work). Another important trigger was sleep deprivation, which seemed to worsen her hallucinations.
Skills assessment determined that she lacked insight into the automatic thoughts that escalated her anxiety and depression. Sue also demonstrated a restricted repertoire of problem-solving skills and was reluctant to talk to others about her problems and fears.
In sum, it appeared that the psychiatric symptoms were controlled by a sequence of environmental and personal instigating influences that began with an overreaction to neighborhood crime, which led to anxiety and fear. These emotions triggered depression and sleep disturbance, which contributed to her more dangerous command hallucinations, no longer effectively controlled by medication.
In order to monitor treatment progress, Sue assessed herself daily on brief measures of anxiety, hopelessness, sleep, and depression. The following interventions were agreed to by Sue, her mother, her psychologist, and her psychiatrist.
1. Sue began planning to move. Within 2 months, with guidance and support, Sue found an apartment in a quiet and safe neighborhood. Sue's aunt moved in with her mother. Immediately after Sue's move, her fear, hopelessness, and depression scores dropped significantly.
2. Risperadal was increased during the move and was subsequently reduced. On the basis of objective, daily self-assessments that Sue provided, the psychiatrist was able to regulate dosage.
3. Sue began a program of daily autogenic biofeedback to reduce her sympathetic arousal and to reduce anxiety. The daily fear and sleep indexes were used to evaluate her progress.
4. Cognitive therapy was initiated to deal with her automatic thoughts, fears, and depression.
5. Sue joined a problem-solving group sponsored by a local mental health clinic for people with schizophrenia.
This combination of interventions, directed by clinical diagnostic hypotheses and generated through MFM, prevented the need for Sue to be hospitalized. Furthermore, knowing those influences that instigated her symptoms allowed Sue and her service providers to design interventions that reduced her skill deficits and to adjust interventions as her conditions changed (based on daily assessments); the knowledge also empowered Sue and enabled her to take control of her life.
Therapeutic Contracting Program
Therapeutic contracting ( Heinssen, Levendusky, & Hunter, 1995 ) is an effective model for persons with serious mental illness because it overcomes resistance, denial, and amotivation in many individuals while enhancing their self-efficacy. It is unique in that it combines contracting with activation of the client's support network, including family but especially other individuals with mental disorders.
The therapeutic contracting program (TCP) is based on weekly meetings in which treatment objectives are developed and progress is reviewed. The goal-setting contracts structure problem-solving experiences that promote the internalization of self-control, self-evaluation, and self-corrective reactions. The program is competency-based and integrates a variety of individually selected cognitive, behavioral, and social learning strategies with appropriate biological and medical interventions.
A distinctive and influential component of the TCP is relationship building among peers and the use of supportive interactions in treatment. Clients and peers assist each other in defining problems, formulating alternative solutions, and selecting alternatives for implementation. They provide support for contract compliance and review each other's success. Many clients experience for the first time in their lives an opportunity to be a positive influence in another's life, to be a caregiver, and to influence meaningful change in others. This initiates new self-concepts of worth and value in the helpers and nurtures the belief that change is also possible within themselves. For treatment resistant patients, the input and assistance of peers may be the deciding variable that encourages participation in therapeutic endeavors.
Case Management and Community Treatment
Scott and Dixon (1995a ) reviewed the literature on case management and differentiated between obsolete models that merely link clients to services and modern programs that provide sophisticated in vivo problem-solving and skills training. The most widely recognized model of this latter type is assertive community treatment (ACT; Test, 1992 ), which provides in vivo services over a long period of time and is an example of the targeted—intermittent long-term therapy model described earlier in this article.
Treatments like ACT can play an important role in managing mental health care. This managed care function is provided in the following ways. First, therapeutic case management is reserved for only those individuals who are at risk of hospitalization and need long-term monitoring and treatment. Second, case managers who are well familiar with the client and the treatments available ensure that community-based outpatient treatments are well coordinated and used to their fullest extent before resorting to more restrictive and expensive treatments, such as hospitalization. Third, a skilled case manager is a powerful therapeutic agent who can teach adaptive social skills in the client's real life environment where they are most needed and are most likely to be learned.
Psychologists have not embraced case management and in vivo treatments as part of their routine clinical practice. However, psychologists trained in cognitive—behavioral skills training interventions are better prepared than any other profession to provide the home- and community-based skills training needed by clients with serious mental disorders. As the influence of managed care and capitated funding expands, case management that includes active therapeutic outreach may provide an opportunity for the expansion of psychology services. In the past, these types of services have not been adequately reimbursed. This reimbursement may change as practitioners are encouraged to develop cost-effective programs of treatment that are based on clinical outcomes rather than fee-for-service models. Psychologists who are willing to adapt their practices to this effective model of treatment will be valuable in a capitated program of treatment funding.
Case management can be augmented by the utilization of paraprofessionals and trained consumers as part of the treatment team. It is well recognized that mental health professionals generally are limited in their ability to relate to persons with severe and long-lasting mental illness because of differences in socioeconomic status, limited accessability, and lack of true awareness of the client's community. The use of indigenous workers helps to correct this situation. The structured treatment models of social skills training and case management readily lend themselves to partnerships between paraprofessionals, who can actively reach the consumer in the community, and psychologists. Psychologists have shown leadership in this area, and evaluations of the effectiveness of peer-assisted treatment have been reported ( Edmundson, Bedell, & Gordon, 1983 ; Felton et al., 1995 ).
Multiple Family Therapy
Family participation in the long-term treatment and rehabilitation of persons with serious mental disorders taps into an important resource available to psychologists working with these clients. Dysfunctional patterns of family interaction can be remediated by the use of social skills training, thus reducing stress experienced by the client. Also, the supportive aspects of families can be incorporated into the client's treatment. A problem-solving-oriented method of multiple family therapy (MFT) was first developed by Anderson, Reiss, and Hogarty (1986) , which also facilitated supportive social network development among families. This treatment is based on a psychological model of psychoeducation, problem solving, and social network development for the treatment of persons with schizophrenia. The original model was adapted for use in a rehabilitation-oriented program of treatment and has been described in detail elsewhere ( Bedell et al., 1994 )
Many persons with serious mental illnesses are hampered by deficits in information processing, including problems with attention, memory, decision making, and expression ( Green, 1996 ; Keefe, 1995 ; Spaulding, Reed, Poland, & Storzbach, 1996 ). These deficits interfere with social functioning and the ability to learn new and adaptive skills. The amelioration of these kinds of functional deficits is often considered to be fundamental to the treatment of persons with serious mental illness.
Innovative and Experimental Treatments for Cognitive Deficits
One might think that antipsychotic and other psychotropic medications would alleviate the information processing deficits of serious mental illness. However, research is mixed regarding this hypothesis, and some studies suggest that traditional antipsychotic and anti-Parkinsonian medications actually worsen attention and memory ( Corrigan & Penn, 1995 ). A variety of psychological treatments have been shown to help resolve information processing deficits. Unfortunately, most studies on cognitive rehabilitation have been conducted in laboratory settings, so the ecological validity of their findings is questionable ( Corrigan & Storzbach, 1993 ; Ellis, 1986 ). What does paying attention to numbers flashing on a computer screen have to do with an individual's ability to attend to and follow his supervisor's instructions about loading a truck?
These limitations notwithstanding, these treatments provide the practitioner with ways of focusing on aspects of treatment previously believed to be outside of the practice of psychology. We present some of the most promising innovations.
Contingent Reinforcement and Punishment
Various reinforcement and punishment contingencies have been shown to improve significantly participants' attention to test stimuli ( Karras, 1968 ; Meiselman, 1973 ; Wagner, 1968 ). Monetary reinforcers and rule learning have improved participants' ability to flexibly manipulate concepts ( Bellack, Mueser, Morrison, & Podell, 1990 ; Green, Satz, Ganzell, & Vaclav, 1992 ). For example, persons in a card-sorting task were able to more accurately sort these cards when paid for correct sorts and when provided one of the rules that guided the sort (e.g., sort by color).
Researchers have attempted to remediate the cognitive deficits of serious mental illness by directly reinforcing and punishing psychotic symptoms ( Corrigan & Storzbach, 1993 ). Punishing contingencies have been used effectively to decrease a person's report about hallucinations or delusions; for example, a research participant self-administered a weak shock each time he talked about his voices ( Bucher & Fabricatore, 1970 ; Weingaertner, 1971 ). This intervention is problematic, however. Persons participating in this treatment may not be less delusional or experiencing hallucinations less frequently. Rather, they are merely not reporting their experiences of delusions and hallucinations to staff members, a poor outcome for many persons who report these symptoms to be stressful.
Liberman and Corrigan (1992) recommended that persons with serious mental illness should monitor their psychotic symptoms daily. These persons should then implement a well-rehearsed coping plan when target symptoms increase markedly from baseline. For example, persons might hum the national anthem when they hear voices ( Green & Kinsbourne, 1993 ). Meichenbaum and Cameron (1973) taught participants self-statements ("I will attend closely to the TV screen") to use during tests of information processing. This kind of directed self-talk led to significant improvement on targeted cognitive tests. Semantic encoding, in which participants are instructed to remember word lists in terms of important dimensions (e.g., rate each word for pleasantness), has significantly improved the subsequent recall of these words ( Koh, 1987 ).
Research by Harrow, Lanin-Kettering, and Miller (1989) suggested, however, that persons are poor monitors of their own psychotic symptoms. Results of their study showed that persons with schizophrenia can accurately identify disorganized statements spoken by peers on an audiotape, but they cannot identify similarly disorganized statements made by themselves. These findings suggest that persons with serious mental illness need to be trained how to self-monitor psychotic symptoms if coping skills are to be a major part of treatment.
Research suggests that social cognitive deficits (e.g., social perception and interpersonal problem solving) occur independently from information processing deficits and, therefore, need to be targeted directly ( Corrigan & Toomey, 1995 ; Penn, Corrigan, Bentall, Racenstein, & Newman, 1997 ). Studies on remediating social cognitive deficits have borrowed strategies for information processing deficits to target social—cognitive deficits. For example, an attention focusing procedure has been shown to augment the acquisition and generalization of basic conversation skills (Liberman, Mueser, Wallace, Jacobs, Eckman, & Massel 1986; Massel, Corrigan, Liberman, & Milan, 1991 ; Wong & Woolsey, 1989 ). This procedure involves repetition of attentional prompts over the course of learning a new skill. An assistant begins a trial by making a predetermined statement to the participant, for example, "I went shopping last night." If no response or an inappropriate reply is made, the trainer prompts, "Ask her a question about her shopping trip." If the participant continues to respond incorrectly, the trainer tries a more directive level of prompts; "You might say, 'What did you buy?"' Attention focusing has led to significant increments in skill learning.
This technique has been used to improve the social—perceptual deficits of persons with schizophrenia ( Corrigan, Nugent-Hirschbeck, & Wolfe, 1995). After watching a 60-second vignette of a social interaction, research participants were instructed to put the gist of the story into their own words. These participants recalled significantly more of the story compared to a control group that was instructed to "watch the story carefully."
Brenner and his colleagues ( Brenner, Boker, Hodel, & Wyss, 1989 ; Brenner, Hodel, Roder, & Corrigan, 1992 ; Spaulding, 1994 ) devised a particularly ambitious program to ameliorate the social—cognitive deficits of persons with serious mental illness. It is a hierarchical program that begins with rehabilitation exercises to remediate relatively micro deficits in information processing (e.g., participants learn to discriminate stimulus categories by completing card-sorting tasks). The program then moves participants from tasks that address relatively micro deficits to more social—cognitive tasks. In one exercise, participants must be able to discriminate important social stimuli from irrelevant distractions as depicted in slides of persons interacting.
Participants who master these primary information processing tasks are ready to move to relatively molar social—cognitive skills. At the highest end of the program, participants learn interpersonal problem-solving skills: how to identify problems that impede their interpersonal goals, brainstorm solutions to these problems, evaluate the costs and benefits of each solution, and develop an implementation plan for the selected solution. Targeting social—cognitive deficits seems to lead to more generalizable deficits. However, future research must examine whether improvements in learning basic conversation skills and perceiving social situations leads to real increases in social competence.
As may be seen from the information presented in this article, there are many new, interesting, and exciting ways for psychologists to apply their skills to address the assessment and treatment needs of persons with serious mental disorders. Much of the training in psychology lends itself to be adapted to this client group. As indicated by Lefley and Cutler (1988), psychology may be the "best suited of all the professions" (p. 256) to address many of the key issues related to the understanding and treatment of these clients. There is little doubt that persons with serious mental disorders will comprise an increasing proportion of clients available for psychological treatment. We hope that the information presented in this article will encourage practitioners to apply their skills in the innovative ways suggested.
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