Andrew I. Schwebel
Department of Psychology Ohio State University
Ryan L. Dunn
Department of Psychology Ohio State University
Stephanie D. McIver
Department of Psychology Ohio State University
American Psychologist, September 1993 Vol. 48, No. 9, 966-971
In addition to suffering from the severe psychiatric symptoms of chronic mental illness (CMI), people with this type of disorder suffer from a variety of secondary disabilities and face societal obstacles that interfere with their ability to maximize their personal, social, and vocational potentials. Following the deinstitutionalization of long-term psychiatric patients in recent decades, many different understandings of the etiology, treatment, and management of CMI have evolved, including those derived from the biological, vulnerability, cognitive, case management, rehabilitation, and psychoeducational models. Because psychologists are trained in a wide range of psychological theories and a broad repertoire of applications, they have unique contributions to make within each model, particularly, as discussed here, to prevent, treat, and manage CMI through research, assessment, and intervention.
One of the most remarkable events in psychiatric health care in the United States in this century was the national deinstitutionalization of people with chronic mental illness (CMI). The number of patients in psychiatric hospitals declined from 557,000 in 1955 to approximately 112,000 in 1988 ( Torrey, 1988 ). Although thousands of long-term patients left psychiatric hospitals, deinstitutionalization by itself failed to meet its proponents' high expectations. Many discharged patients developed a pattern of frequent readmissions for brief stays, whereas others were reinstitutionalized in nursing homes, boarding homes, and other facilities that were ill-equipped to deal with the unique needs of the increasing numbers of patients with CMI ( Bellack & Mueser, 1986 ). In addition, as many as one half of homeless people are former patients at psychiatric hospitals ( Bellack, 1986 ), and large numbers are in prison, where 5% to 10% of the inmates may have a mental illness ( Torrey, 1988 ; Warner, 1989 ).
Chronic mental illness is difficult to define. Before deinstitutionalization, the criterion for chronicity was current or prior hospitalization ( Bachrach, 1988 ). Present definitions emphasize three criteria: duration, diagnosis, and disability ( Bachrach, 1988 ). First, chronic illness is distinguished by its gradual onset, indefinite duration, threat of relapse, and lack of return to prodromal functioning. Acute illness, in contrast, has an abrupt onset and finite duration (Anderson, cited in Wintersteen, 1986 ). The second criterion is diagnosis, which is made on the basis of psychiatric symptoms, such as depressed mood, hallucinations, or delusions. A diagnosis of schizophrenia implies chronicity, almost by definition, because of its generally poor prognosis. The third criterion is disability. In addition to the severe psychiatric symptoms suffered in CMI, secondary disabilities are also present that lead to considerable financial, social, vocational, and personal impairment.
Because CMI is characterized by chronic deficits in personal and social functioning, many people with CMI are unable to perform the basic activities of daily living. Many are unemployed, are dependent on welfare services for survival, and lack adequate health care. In addition, the chronically mentally ill must also deal with stigma and discrimination. These factors combine to make them "one of the most needy and disadvantaged groups of society" ( Shadish, Lurigio, & Lewis, 1989, p. 7 ).
Recent articles have pointed to a growing consensus that the problems of CMI should be a national mental health priority ( Ahr & Holcomb, 1985 ; Youngstrom, 1991 ). Outspoken advocates for the chronically mentally ill, such as psychiatrist E. Fuller Torrey and the National Alliance for the Mentally Ill, have called for psychologists to assume a leadership role in caring for people with CMI ( Youngstrom, 1991 ).
A more extensive involvement of psychologists in work with people with CMI is possible since deinstitutionalization. For example, several new models of CMI have been developed that offer psychologists the opportunity to use their expertise in various ways in various ways in serving people with CMI. However, psychologists have not responded by assuming the full range of roles that are available under these models.
Our purpose in this article is to summarize and synthesize existing views of CMI and to suggest possibilities for greater involvement by psychologists. Toward these ends, we outline six current models of CMI that can be conceptually distinguished but that are not mutually exclusive. Under each model we specify roles for which psychologists are trained and through which they can make valuable contributions. The description of these roles is meant to be illustrative rather than exhaustive.
The dominant model of CMI before deinstitutionalization (and afterward as well) was the biological model. Until the 1950s, the primary treatment for CMI was hospitalization, and the roles of psychologists were clearly delineated and delimited. However, as deinstitutionalization changed the character of the biological model, the roles of psychologists within this model also changed.
The Biological Model: Hospitalization Key position.
The biological model assumes that psychiatric illnesses are diseases with biological causes (Andreasen, cited in Hatfield, 1990 ).
The dominance of the biological model has had three main consequences. First, physicians or psychiatrists assumed primary responsibility for treatment. Second, somatic therapy was emphasized rather than psychological treatment (Andreasen, cited in Hatfield, 1990 ). Thus, people with CMI were hospitalized and, until deinstitutionalization, experienced years of confinement and separation from family, friends, and community.
Roles for psychologists.
Before deinstitutionalization, the roles of the mental health specialities were clearly delineated: Psychiatrists diagnosed illness and prescribed medication, nurses administered medications and helped the clients with their social and daily living skills, and social workers dealt with the family (see Herr & Cramer, 1987 ). Within the hospital context, psychologists performed research, assessments, and interventions but worked under the supervision of physicians.
Beginning in the 1950s, social, ideological, and economic factors contributed to the release of people with CMI from institutions ( Bellack & Mueser, 1986 ; Shadish et al., 1989 ; Warner, 1989 ). The introduction of antipsychotic medications in the 1950s had the most significant impact. Although not a "cure," these drugs effectively reduced psychotic symptoms and allowed many patients to return to the community. A second important factor was the development of the community mental health movement, which provided health care at a community level rather than exclusively through centralized institutional settings. This movement received impetus from studies showing the negative effects of institutionalization and the stigma of hospitalization on patients ( Wing & Brown, 1970 ).
Whereas the hospital provided for the basic needs of its patients in one setting, deinstitutionalization resulted in the decentralization of health care services. Patients in the community were then faced with providing for their own needs. Their tasks included meeting basic biological needs (food, shelter, clothing, and hygiene); obtaining medical care in the community; and finding housing, work, transportation, and social activities, all of which were made more difficult by the handicapping disability and social stigma resulting from their illnes. Many deinstitutionlized patients lacked adequate social and self-care skills to meet these needs without assistance.
The introduction of medications, the community mental health movement, and deinstitutionalization resulted in several broad changes in the treatment of people with CMI. One change involved adjusting the biological model to support outpatient treatment for people with CMI. Under this new focus, psychiatrists dispensed medications, while other professionals provided adjunctive services to help deinstitutionalized patients meet their basic needs.
A second significant change was the development of several new models of CMI that serve as adjuncts to the biological model. Like the biological model, the vulnerability and cognitive models primarily emphasize etiological theories of CMI. In contrast, the case management and rehabilitation models are primarily concerned with the consequences, rather than the causes, of mental illness, focusing on the management of CMI, rather than its cure. Finally, the psychoeducational model is distinguished by its focus on intervention with the families of people with CMI, providing them with information and support. Besides having implications for patients and their families, these models have changed the character of career possibilities for psychologists by providing new opportunities in the area of CMI.
Etiological Models: The Biological Model in Community Treatment Key position.
As stated earlier, this model assumes that CMIs are diseases with biological causes.
The biological model continues to be the prevailing model. In fact, the finding that antipsychotic medications controlled many of the symptoms of CMI seemed to confirm the biological interpretation of many mental health professionals. However, drawing the conclusion that the etiology of CMI is solely biological on the basis of the evidence of the effectiveness of medication is a logical error. Although biological factors are obviously important, this extreme position overlooks the possibility that medications may treat only symptoms and ignores other factors that might cause or contribute to CMI.
The strict partitioning of functions under the biological model in the past, which unnecessarily restricted psychologists' role in CMI, has been undergoing change. The increasing recognition of other factors that influence the course of CMI allows psychologists to make valuable contributions when a biological model is assumed.
Roles for psychologists.
Roles that follow from this model areResearching diagnostic categories in order to refine their reliability and validity. Reliable diagnosis is a necessary first step for research in the etiology and treatment of psychiatric disorders.Etiological Models: The Vulnerability Model Key position.
Developing and applying measures to assess the effectiveness of medications. When drugs are used to treat symptoms of psychopathology, the primary criterion for their success is behavior change in the patient. Psychologists are well qualified to assess such behavioral changes ( Hargrove & Spaulding, 1988 ).
Intervening to increase medication compliance using behavior management techniques, particularly with discharged patients. Behavioral techniques can also be used to reduce the unpleasant side effects of medications ( Bellack, 1986 ).
The vulnerability model expands the classic biological model by attributing mental illness to the interaction of biological factors and psychosocial stress. It argues that individuals do not inherit a mental illness itself but, instead, a vulnerability or a predisposition to develop the illness under stress.
This model persuasively incorporates findings that both biological and environmental factors contribute to the onset of schizophrenia. Although biological factors have undeniable importance in CMI, biochemical changes may primarily serve to mediate the relationship between psychosocial causes and the development of symptoms of CMI. Thus, CMI may be best understood as an interaction between biological and psychosocial factors ( Bellack, 1986 ; Bowers, 1980 ; Harding, Zubin, & Strauss, 1987 ). When sustained over a long period of time, psychosocial stresses may cause chemical changes in the body that result in irreversible structural changes in the nervous system.
Roles of psychologists.
Roles that follow from this model areResearching the effects and management of stress.Etiological Models: The Cognitive Model Key position.
Developing and applying measures to assess both the stress experienced by individuals and the internal and external resources available to cope with that stress.
Intervening to reduce stress in the lives of vulnerable individuals, thus reducing the risk of mental illness and preventing rehospitalization. Psychologists can do this by teaching stress management skills (e.g., to identify stressors, manage stress, and solve problems), environmental management skills, and the social skills necessary to build their social networks. Although vulnerable individuals are thought to have lower thresholds for stress, social support has been shown to buffer stress and reduce vulnerability to both physical and mental illness ( Cohen & Wills, 1985 ; Holmes-Eber & Riger, 1990 ). Psychologists can also teach clients and family members to recognize the early signs of impending illness and develop strategies to reduce its likelihood.
Cognitive models suggest that CMI can be effectively understood in terms of information-processing deficits. Once these deficits are identified, cognitive interventions are used to correct them and reduce psychiatric symptoms ( Jacobs, 1980 , 1982 ; Perris, 1990 ).
Cognitive models characterize the core deficit in CMI as a set of systematic cognitive distortions that bias the patient's experience and maintain the disorder (e.g., Beck & Emery, 1985 ; Ellis, 1986 ). For example, cognitive models of schizophrenia characterize the core deficit in this disorder as a defective attentional filter that results in information overload ( Adams, Malatesta, Brantley, & Turkat, 1981 ; Anderson, Hogarty, & Reiss, 1980 ). Cognitive treatment teaches patients to examine and evaluate their cognitions and to substitute more adaptive ones. Adams et al. (1981) successfully used behavioral techniques to teach patients with CMI to attend to appropriate stimuli and to use thought stopping to eliminate inappropriate thoughts.
Roles for psychologists.
Roles that follow from this model areResearching clients' cognitive processes in order to identify the core cognitive deficits associated with CMIs.Cognitive interventions can also be used to combat hopelessness and to disrupt negative self-fulfilling prophecies. By increasing clients' expectations of success, psychologists may enhance the efficacy of treatment ( Gomez-Schwartz, 1978 ).
Developing and applying measures to assess the cognitive deficits present in clients with CMI. This would allow interventions to be tailored to the individual patient.
Intervening with cognitive techniques directly to remedy cognitive and behavioral deficits ( Erickson, 1989 ; O'Connor, 1984 ). For example, psychologists can use self-instructional training to help patients with schizophrenia to function more appropriately in social situations ( Meichenbaum & Cameron, 1973 ; Meyers, Mercatoris, & Sirota, 1976 ) or to examine treatment-related cognitions to increase medication compliance ( Davidhizar, 1984 ).
Management Models: The Case Management Model Key position.
The case management model was developed to provide support to clients. It helps them link with resources and manage their illness over the long term, rather than trying to identify and treat the causes of their disorders.
Because the introduction of community mental health centers produced a decentralized system of health care, the coordination of services became a major problem. The case management approach represents one solution to this problem. Under earlier versions of this model, a case manager functioned primarily as a service broker, working actively to link clients with available resources ( Intagliata, 1982 ). Later versions of the case management model involved a much broader spectrum of functions including (a) assessing the needs and resources of the client, (b) planning treatment for the client, (c) linking the client with resources, (d) monitoring the client and evaluating the effectiveness of treatment, and (e) advocating for the client ( Intagliata, 1982 ; Johnson & Rubin, 1983 ). The range of functions necessary in comprehensive case management requires a variety of skills. Because of the many functions required, a team approach is often used.
Roles for psychologists.
Roles that follow from this model areResearching intervention models and conducting program evaluations of treatment approaches and services provided to clients.Management Models: The Rehabilitation Model Key position.
Developing and applying measures to assess the needs of the clients in order to determine the most appropriate resources to help them in their daily living.
Intervening as part of the case management team as well as serving as a treatment resource for clients. Psychologists can also train colleagues in a variety of case management skills.
The emphasis in this approach is on training clients in the skills necessary to reduce their impairment, rather than trying to identify and treat the causes of their disorders ( Anthony, 1977 ; Anthony & Liberman, 1986 ).
The rehabilitation model differentiates between the symptoms of psychiatric illness and secondary disabilities, which are social and occupational deficits that result from the illness but are not inherent in the illness itself. Proponents of the model argue that although medication treats certain psychiatric symptoms, such as hallucinations and delusions, it has been unsuccessful in addressing secondary deficits and disabilities that families and the community find troubling, such as social withdrawal and apathy ( Gittelman, 1988 ; Shepherd, 1988 ). Skills training and support are necessary to address clients' disabilities and maximize their potential to adequately perform social, vocational, and daily-living role functions ( Anthony & Liberman, 1986 ).
Roles for psychologists.
Roles that follow from this model areResearching the effectiveness of rehabilitative programs.Advocacy is also important in this model ( Anthony & Liberman, 1986 ). Community members often hold negative attitudes toward persons with mental illness ( Rabkin, 1972 ), and unfortunately, these negative attitudes are often shared by mental health professionals ( Lefley, 1988 ). Psychologists can promote positive attitudes toward persons with CMI through involvement in community and professional education and in the administration of programs concerned with CMI.
Developing and applying measures to assess disabilities in functional rather than categorical terms, that is, assessing the specific behavioral skills and deficits of individuals rather than assigning them diagnostic labels ( Wallace, 1986 ). Behavioral psychologists have developed many refined techniques of functional assessment that can be applied ( Hargrove & Spaulding, 1988 ).
Intervening to correct the deficits observed through functional assessment. Behavioral and skills training approaches can increase the clients' role functioning and help them develop support systems in the environment ( Douglas & Mueser, 1990 ; Wallace et al., 1980 ).
Family Intervention Model: The Psychoeducational Model Key position.
Versions of the psychoeducational model were developed for several reasons: to provide support to family members, to decrease their stress, and to increase their effectiveness in caretaking ( Anderson et al., 1980 ; Falloon, 1985 ; McFarlane, 1983).
In the past, families of people with CMI were often identified by mental health professionals as the cause of the illness and were often excluded from treatment decisions ( Wynne, 1981 ). After deinstitutionalization, however, family members became the primary caretakers of their relatives with CMI ( O'Connor, 1984 ), and researchers began to focus on the family as a reactor to, rather than a cause of, mental illness ( Gubman & Tessler, 1987 ).
In addition to the bizarre symptoms and behaviors of the ill person and stigma from the community, family members must cope with stress and conflict in the household, disruption of their personal lives, and personal reactions such as depression, grief, guilt, resentment, and anger ( Bernheim, 1989 ; Hatfield, 1978 ). To cope with their burdens, families consistently report a need for more information and support from mental health professionals, especially regarding the nature and management of the illness ( Group of the Advancement of Psychiatry, 1986 ; Hatfield, 1983 ).
Roles for psychologists.
Roles that follow from this model areResearching the effectiveness of educational programs.Psychologists can also teach family members skills that will help them to become more effective caretakers and cope more effectively with the bizarre behavior of the ill family member ( Falloon, 1985 ; Falloon & Liberman, 1983 ). For example, by reducing the amount of expressed emotion (defined as critical comments directed toward the patient and overinvolvement in the patient's affairs) in the family environment, caregivers can reduce the risk of the patient's relapse ( Leff, Kuipers, Berkowitz, Eberlein-Vries, & Sturgeon, 1982 ).
Developing and applying measures to assess the family members' level of knowledge about CMI, the burdens they experience, and their attitudes toward the mentally ill family members.
Intervening to provide family members with information about the nature, etiology, and treatment of mental illness.
Finally, psychologists can provide support for patients' family members, teaching them skills for coping with stress and for expanding their social networks ( Anderson, 1983 ; Anderson et al., 1980 ; Falloon, 1985 ). Family therapy may help the family cope with the grief, guilt and anger of having a mentally ill family member and deal with any other problems that may make caregiving more difficult.
There is a critical need for psychologists to become more active in the prevention of mental health problems ( Pransky, 1991 ). In preventing CMI, regardless of the model that is assumed, a first step forward is building better understandings of the conditions affecting the nature, onset, and course of chronic mental illness (e.g., Albee, Bond, & Monsey, 1992 ). Obviously, psychologists are well prepared to make substantial contributions in these areas.
The Role of Psychologists: Prevention
In order to better specify the breadth of the area of prevention and the roles that psychologists can assume, we draw upon a useful framework characterizing prevention as primary, secondary, or tertiary ( Caplan, 1964 ). Primary prevention refers to broad efforts to decrease the incidence of CMI, or number of new occurrences, through individual and community change. Secondary prevention refers to decreasing the prevalence or number of cases of CMI at any given time. This is accomplished through screening aimed at the early detection of mental illness and providing crisis intervention with high-risk groups. Tertiary prevention refers to decreasing the short- and long-term severity of symptoms of individuals already affected by CMI. In practice, tertiary prevention interventions appear to be very much like treatment. However, whereas the principal aim of treatment is to remedy present occurrences of the illness, the aim of tertiary prevention is to prevent or reduce the severity of future occurrences of the illness.
Over the long term, primary prevention efforts appear to promise the best payoff, although they are generally the most difficult to implement. Such programs in the area of CMI could focus on preventing individuals from developing CMI by helping them become competent, healthy persons, characterized by their psychological and physical wellness. Primary prevention programs, Cowen (1986) suggested, would have two thrusts: a systems-level strategy, which would reduce the stress individuals experience while providing them with ample personal opportunities for development, and a person-centered strategy, which would strengthen individuals' abilities to effectively cope with whatever stressors they faced. Thus, primary prevention efforts would be broad-based, directed at alleviating social problems associated with the onset of CMI, such as poverty, and, at the same time, fostering the development of personal competencies in both healthy and "at-risk" individuals.
To illustrate the role of psychologists in primary prevention, we use the vulnerability model as an example. The vulnerability model recognizes the interaction of both biological and psychosocial factors in the onset of CMI. Psychologists could, perhaps, have the greater impact by intervening with psychosocial factors. This could consist of a twofold approach. First, psychologists could work to alleviate, where possible, the stressful conditions in the environment that contribute to the onset of CMI. Second, psychologists could work to promote the mental health of the population at large and to increase peoples' resiliency in the face of stressful conditions that cannot be eliminated.
Interventions at the level of secondary prevention generally require less time and money to develop and thus are more readily implemented by psychologists. To illustrate the role of psychologists in secondary prevention, we again use the vulnerability model as a framework. Psychologists can identify people at risk for developing CMI and attempt to reduce stress that might contribute to the onset of a disorder by providing education, treatment, and support in crises. In addition, psychologists can increase the competence of people at risk through skills training and other means, enabling them to better cope with stress and thus avoid the onset of exacerbation of symptoms of mental illness.
Interventions at the level of tertiary prevention generally require the least change in professional practice to implement, partly because the roles of psychologists in such interventions are much like the roles they already play in treatment. Using the vulnerability model to illustrate, psychologists engaging in tertiary prevention, besides treating current symptoms, would try to prepare patients to better cope with future stress. For example, they might teach patients skills they could use to reduce the impact of future stressors or strengthen patients in ways that make them more resilient.
In conclusion, each of the models we have discussed contributes to our overall understanding of CMI by focusing on different aspects of etiology and treatment. Taken together, these models point to the fact that CMI is a problem with multiple biological, individual, and social determinants and that in studying or treating it, scientists and health providers must consider a broad range of factors. We have suggested some of the many roles that psychologists can fill in the research and treatment of CMI and in the development of prevention programs.
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