Treatment and Rehabilitation of Severe Mental Illness


Synthesizing the growing body of biomedical and psychosocial research on the nature and treatment of severe mental illness, this volume presents an innovative framework for planning and implementing effective rehabilitation services. An integrative model of case formulation is described that conceptualizes the individual's recovery on multiple levels: physiological, cognitive, interpersonal, behavioral, and environmental. The authors draw on outcome research and extensive clinical experience to identify ...
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Synthesizing the growing body of biomedical and psychosocial research on the nature and treatment of severe mental illness, this volume presents an innovative framework for planning and implementing effective rehabilitation services. An integrative model of case formulation is described that conceptualizes the individual's recovery on multiple levels: physiological, cognitive, interpersonal, behavioral, and environmental. The authors draw on outcome research and extensive clinical experience to identify interventions of known effectiveness, including psychopharmacology, functional assessment, behavioral analysis, and cognitive therapies. Outlining a comprehensive approach to assessment, treatment, and progress evaluation, the book also provides practical recommendations for program development and staff training.
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Editorial Reviews

From the Publisher

"Spaulding et al. compellingly argue that the adoption of a new, integrated model of treatment is long overdue, particularly when dealing with severe mental disorders. This book provides a framework that is at once theory-driven, based in the cumulative findings of outcome research with the severely mentally ill, and firmly grounded in the authors' long history of work in the field. Presented is a truly pragmatic approach that, if successfully applied, promises to considerably enhance service provision to this challenging population. I strongly recommend this book for mental health policymakers, clinicians, and researchers. Graduate psychology students, especially those in psychopathology or clinical interventions courses, will find the book's integration of theory and sound practice guidance to be of immense utility."--Morgan T. Sammons, PhD, Mental Health Department, Naval Medical Clinic, Annapolis, Maryland

"Every student, scientist, and practitioner who wants to know where psychiatric rehabilitation is headed needs to read this book. The authors, national leaders in psychopathology and rehabilitation, combine their intellectually varied backgrounds to bring clarity to the confusion and disagreement that characterize current practices in psychiatric rehabilitation. The book's remarkably satisfying synthesis provides the scientific foundation for an action agenda for 21st century psychiatric rehabilitation. A biosystemic paradigm is used to give logical coherence to clinical assessment, formulation, and rehabilitation planning. So comprehensive is the authors' approach that they are able to conclude with a detailed algorithm for treatment and rehabilitation of schizophrenia. This book is an invaluable source of scholarship, clinical insight, and practical advice for anyone who seeks to understand disabling mental illness and to improve the lives of those who face its daily challenge. As a text, it will be suitable for graduate students in psychology or rehabilitation and for psychiatric residents in specialized programs in community psychiatry."--Morris Bell, PhD, ABPP, Yale University School of Medicine and Department of Veterans Affairs, Rehabilitation Research and Development Service

"This is one of the handful of books that should be on the desk of every mental health professional, researcher, administrator, and advocate concerned with understanding people with severe psychiatric disabilities and providing effective interventions. The authors provide a unique conceptual foundation for rehabilitation that draws on empirical research on biological, behavioral, and social factors. Their comprehensive, unified approach combines rigorous analysis with humanitarian understanding. Students and professionals alike will gain from this book not only a conceptual structure on which to build specific skills, but also an understanding of what it takes to create, implement, and lead cost-effective rehabilitation programs. Highly recommended as a text in graduate and upper-division courses in psychology, psychiatry, rehabilitation, social work, and mental health administration."--Gordon L. Paul, PhD, Department of Psychology, University of Houston

Bulletin of the Menninger Clinic

"...this book is recommended for clinicians who would like an historical overview of the changes in mental health services and approaches to patients with severe mental illness, as well as the presentation of one useful treatment model."--Bulletin of the Menninger Clinic
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Product Details

  • ISBN-13: 9781572308411
  • Publisher: Guilford Publications, Inc.
  • Publication date: 2/1/2003
  • Edition description: New Edition
  • Edition number: 1
  • Pages: 386
  • Product dimensions: 6.20 (w) x 9.00 (h) x 1.20 (d)

Meet the Author

William D. Spaulding, PhD, received his doctorate in clinical psychology at the University of Arizona in 1976. He completed a postdoctoral fellowship in mental health research and teaching at the University of Rochester School of Medicine and Dentistry. Dr. Spaulding is currently Professor of Psychology in the Clinical Psychology Training Program, Department of Psychology, University of Nebraska/n-/Lincoln, and a Clinical Psychologist in the Community Transition Program, Lincoln Regional Center.

Mary E. Sullivan, MSW, received her masters in social work from Syracuse University in 1978. She also received a certificate in health studies from the Maxwell School of Citizenship and Public Affairs, Syracuse University, in 1978. She is currently Program Director of the Community Transition Program, Lincoln Regional Center, and Adjunct Clinical Assistant Professor in the Department of Psychology, University of Nebraska/n-/Lincoln.

Jeffrey S. Poland, PhD, received an MA in clinical psychology from Southern Connecticut State University in 1982 and a doctorate in the philosophy of science from Massachusetts Institute of Technology in 1983. He has held positions at Colgate University and the University of Nebraska/n-/Lincoln, and he currently teaches in the Department of History, Philosophy, and Social Science at the Rhode Island School of Design. Dr. Poland has published articles on such topics as the unity of science, psychiatric classification, and psychopathology.

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Read an Excerpt

Treatment and Rehabilitation of Severe Mental Illness

By William D. Spaulding Mary E. Sullivan Jeffrey S. Poland

The Guilford Press

Copyright © 2003 The Guilford Press
All right reserved.

ISBN: 1-57230-841-9

Chapter One

An Integrated Paradigm

Origins in Psychopathology, Rehabilitation, and Clinical Practice

Rehabilitation is a familiar term with a variety of meanings. In common usage, its meanings range from general sets of assumptions, values, and goals, to very specific clinical techniques. The term "psychiatric rehabilitation" is used extensively to describe the rehabilitation of people with severe mental illness, but there are different schools of thought and technologies even within the psychiatric rehabilitation community. When it comes to actual clinical practice and the development and provision of mental health services, confusion and disagreement about what constitutes rehabilitation remain, especially as it is applied to the treatment of people with severe mental illness.

There are a number of reasons for this ambiguity concerning rehabilitation. Historically, its application to mental illness derives from earlier theoretical systems and technologies, especially the psychology of physical rehabilitation, but also clinical psychology, social learning theory, social psychiatry, occupational therapy, and others, plus more recent contributions from the biological and cognitiveneurosciences. Application of rehabilitation to people with mental illness has evolved over several decades. Specific treatments and related technologies have been added to its armamentarium by various research groups at various times, and its underlying premises and values have been shaped by the involvement of advocates, consumers, recipients, and other constituencies. The recipient population is highly heterogeneous, and different subpopulations and individuals benefit from different combinations of specific treatments within the broader armamentarium. Different rehabilitation goals are suitable for different individuals-a situation that requires considerable tailoring of services and discourages a "universal standard" of specific technologies applicable to all recipients.

Today rehabilitation continues to take shape, not just in mental health, but in health care in general. New theoretical insights and technologies are assimilated as they become available. Changing social policy, the politics of health care, and theories of management also affect how rehabilitation is provided, and to whom. (For a current account of rehabilitation outside the mental health domain, see Brandt & Pope, 1997.) It is this multiplicity of factors that creates the vaguely defined and sometimes controversial enterprise of rehabilitation for severe and disabling mental illness.

The rehabilitation field is currently experiencing a recognizable stage of development, characterized by a cacophony of perspectives, that is also showing signs of consolidation and integration-harmony out of cacophony. A premise of this book is that, in the foreseeable future, progress in rehabilitation for mental illness will be characterized not by dramatic new breakthroughs in science and technology but by steady progress toward a more systematic, relational, and effective application of principles and techniques that presently lie in separate, often isolated, domains. For this systems- wide coherence to become a reality, the field of mental health rehabilitation needs a unifying conceptual framework in which all its disparate values, principles, and technologies coalesce to provide a workable, successful product: effective rehabilitation of people who live with disabling mental illness.

The first three chapters of this book construct such a framework, and the succeeding chapters amplify it with specific principles and technologies. In this first chapter, the construction project begins with reflections on the role served by unifying conceptual frameworks, or paradigms, in science, technology, and society. Next, several historical paradigms for understanding and treating mental illness are reviewed. To understand where we are going, it is helpful to take a look at where we have been. Finally, we introduce the three major sources of our rehabilitation paradigm: the social values of rehabilitation, the research findings in the field of psychopathology, and the techniques of clinical case formulation.


A paradigm is a set of interrelated concepts, principles, and methods related to the successful pursuit of some overarching enterprise. In this case, the overarching enterprise is rehabilitation. The paradigm we are proposing to guide the rehabilitation of severe and disabling mental illness includes (1) a set of premises and principles concerning illness, disability, and the purposes of treatment; (2) a collection of interrelated scientific methods and observations; (3) specific clinical technologies; and (4) a systematic approach to providing services to people with disabling mental illness.

A paradigm gives logical coherence to its overarching enterprise and individual meaning to its specific elements-the concepts, methods, treatments, and so on-that the paradigm incorporates. A paradigm is especially important for rehabilitation and related human service enterprises because these enterprises incorporate such diverse elements as social values, behavioral technology, and neuropharmacology. Social values by themselves do not necessarily lead to technical solutions, and the biobehavioral sciences do not necessarily lead to social values. If rehabilitation is to be both socially responsible and clinically effective, it needs a paradigm that establishes logical, conceptual, and ethical continuity between its various elements.

To some, systematic discussion of an approach's underlying paradigm may seem like an abstract philosophical exercise, lacking significant or direct implications for practice. This would be a defensible view for pursuits wherein the logical and philosophical premises are so accepted, or the technologies on which they are based so unequivocal in operation, that the paradigm in which they operate is not subject to productive debate. Electronics is an example. Most would find it quite annoying if the initial chapter of the manual for their new computer were a philosophical discussion of number theory or quantum mechanics. Although those subjects address the most fundamental aspects of how computers work, current controversies over the ultimate meaning of "zero" are unlikely to influence use of computers in our everyday lives. Even when paradigms contain intrinsic contradictions, important applications may remain unaffected. For example, we continue to build both nuclear weapons and radios, even though the paradigms that guide those activities-relativity theory and quantum mechanics, respectively-are theoretically incompatible. (Greene's [1999] account of the development of string theory sheds considerable light on the relationship between paradigms and the progress of science.)

Nevertheless, in certain applications paradigmatic ambiguities create more serious and immediate limitations. For example, the paradigms of law and medicine reflect complex human enterprises and enjoy a good deal of consensus. Both highly value the preservation of human life and have evolved sophisticated praxes for doing so. However, neither law nor medicine has been able to resolve the issue of elective abortion. There are logical and scientific ambiguities about what constitutes "human life" and when it begins. As a result, neither paradigm provides resolution of the issue of what it means to abort a human fetus. Controversy persists at the level of political and religious belief. In the case of mental illness and rehabilitation, there is no paradigm that enjoys the degree of consensus found in electronics, or even medicine or law. As a result, there is pervasive ambiguity about what the goals of rehabilitation should be, who can benefit, or even what rehabilitation and severe and disabling mental illness really mean. As with elective abortion, mental health controversies engage political and religious belief as well as tenets of science, law, and technology.

In mental health services, the judgments of clinicians and the choices of service recipients, consumers, and advocates are all based on some underlying set of premises, often unique and idiosyncratic to the individual, in the absence of a commonly accepted paradigm. As a result, decisions and choices that make sense to one individual may make no sense to others. Equally important, without the moderating influence of broad consensus, many people may harbor premises that are simply false (although, of course, having a paradigm is no guarantee against being wrong). In a mental health service system without a paradigm, policy is driven too little by science, technology, and real social needs, and too much by politics and misconceptions. The success of the rehabilitation enterprise ultimately depends on a sound paradigm to guide the judgments and choices of both providers and recipients.


Paradigms are sociological phenomena, in that they represent the collective beliefs and conventions of a community. In scientific communities, paradigms are associated with philosopher and historian Thomas Kuhn. Kuhn (1962) constructed a now well-known analysis of the formation and change of paradigms in science. As a result, paradigm is often used in the sense of "paradigms as described by Kuhn." However, Kuhn included a number of distinct ideas under the rubric of paradigms, and his analysis has been criticized for being vague and overinclusive in this respect. Furthermore, Kuhn's analysis of paradigms focused on progress in astronomy, chemistry, and physics-barely comparable to the sciences that address mental illness and the enterprise of rehabilitation. In short, much of Kuhn's analysis has questionable relevance to the evolution of rehabilitation paradigms.

Nevertheless, one of Kuhn's most important insights is highly applicable to contemporary rehabilitation: Communities generally tend to adhere to a single, dominant paradigm even while new, alternative paradigms evolve. The new paradigms evolve in response to limitations in the explanatory or practical power of the dominant paradigm. Eventually, the value of the dominant paradigm becomes outweighed by an alternative, and the community undergoes a paradigm shift. The new paradigm brings fundamental changes in key premises and usually an expansion of explanatory and practical power. For example, emergence of the quantum mechanics paradigm provided new explanations of natural phenomena that cannot be explained by Newtonian physics (e.g., the behavior of electrons) and also stimulated invention of modern electronic devices. Old paradoxes are resolved or obviated. The scope of the paradigm itself may change. The cycle then repeats itself, as the new paradigm accumulates disconfirmatory data and its practical limitations become salient.

Kuhn also recognized that paradigm shifts occur in response to developments that are unrelated to competition between paradigms. For example, acceptance of a heliocentric solar system was influenced by European social and cultural evolution as much as by an accumulation of astronomical observations. Paradigms of mental health and illness were historically influenced by social movements (e.g., the French Revolution) and population shifts (e.g., immigration to the New World) as much as by scientific advances (see Magaro, Gripp, McDowell, & Miller, 1978).

The currently dominant paradigm for mental health and illness, in place for at least a century, is creaking under the weight of disconfirmatory data and practical limitations. Extrinsic factors, such as health care politics and consumer activism, are pressuring for change. Attractive alternative paradigms have been appearing for over three decades. If there is a "Kuhnian cycle" in the evolution of mental health paradigms, then the scientific and health care communities seem poised for a shift. A new paradigm is emerging. It incorporates older ones and extends their explanatory power and practical utility. It is recognizably a rehabilitation paradigm, but it incorporates many features that have not previously been included in rehabilitation paradigms.


Paradigms for understanding and treating disabling mental illness have been evolving for at least three centuries. "Moral therapy," which appeared in Europe in the 17th century, is an early example (see Grob, 1973, for a historical account of moral therapy in America); it represented a protoscientific paradigm, in that it had a rational conceptual structure that did not depend on supernatural or theological assumptions but did not incorporate a scientific experimental methodology. The term moral lacked the religious and ethical connotations it has today and was closer to our contemporary use of psychological. In the late 19th century the medical model emerged as the dominant paradigm, and remained so throughout the 20th century. (See Grob, 1983, for a historical account of these developments in America; see Bynum, Porter, & Shepherd, 1988, for a historical account of parallel developments in Europe.) The modern rehabilitation paradigms for mental illness that appeared in the late 20th century represented distinct alternatives to the medical model. It is therefore important to understand the relationship between the older medical model and newer rehabilitation paradigms.

The Medical Model

Medical model is a term used in markedly different ways by different individuals. In the present context, it refers to a paradigm of treatment and service provision in which mental illness is held to be fundamentally and pervasively comparable to medical diseases, which have no psychological or behavioral sequelae. There is a strong connotation that medical treatments have primacy, and that the professionals who control these treatments should control all aspects of the related service system. The community most centrally associated with the medical model is the profession of psychiatry, with its associated guild organizations (the American Psychiatric Association in the United States) and academic institutions (psychiatry departments in medical schools). The medical model includes other professionals as caregivers, "allied health professionals," who collaborate with physicians in a subordinate capacity.

Although many people associate the medical model with biological theories of mental illness and biological treatment technology, the model is not really tied to any particular theoretical view or technology. In the first half of the 20th century American psychiatry was dominated by the theories and practice of psychoanalysis.


Excerpted from Treatment and Rehabilitation of Severe Mental Illness by William D. Spaulding Mary E. Sullivan Jeffrey S. Poland Copyright © 2003 by The Guilford Press. Excerpted by permission.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

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Table of Contents

I. Key Concepts
1. An Integrated Paradigm: Origins in Psychopathology, Rehabilitation, and Clinical Practice
2. The Psychopathology of Disabling Mental Illness
3. The Structure of Clinical Assessment, Formulation, and Rehabilitation Planning

II. Assessment and Treatment Techniques
4. The Neurophysiological Level of Functioning
5. The Neurocognitive Level of Functioning
6. Mechanisms of Neurocognitive Recovery
7. Neurocognitive Interventions
8. Social-Cognitive Processes in Research and Treatment
9. The Sociobehavioral Level of Functioning
10. Person-Environment Interactions

III. The Organization Context of Rehabilitation
11. The Rehabilitation Team: Structures and Processes
12. Administration and Management of Rehabilitation Services

Appendix 1. A Prototype Problem Set for Assessment, Treatment, and Rehabilitation of People with Disabling Mental Illness
Appendix 2. Rehabilitation Plan and Progress Evaluation Documents
Appendix 3. Algorithm for Making Clinical Decisions

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