Historical Paradigms for Treatment of Serious Mental Illness

Table 1.1 Comparison of historical paradigms for assessing and treating severe and disabling mental illness

Conceptual understanding of "mental illness"

Mental illness is a medical disease, reducible to specific
but unknown biological abnormalities; all aspects of mental illness are consequences or complications of the biological abnormalities

The most important expressions of mental illness are in social and interpersonal functioning; mental illness compromises
the person's ability to participate in normal community life

Mental illness impairs
a person's ability
to acquire and
use essential skills,
and to respond
appropriately
to the routine environmental
demands of life

Mental illness is disability to be overcome, not disease to be cured; the important expressions are those which are barriers to normal functioning

Purpose and goal of treatment

If the disease cannot
be cured, the symptoms must be controlled as well as possible; the patient's role is to follow the directions of the
doctor
(psychiatrist)

The purpose of treatment is to participate meaningfully and effectively in community life; the
role of people in treatment
is to participate in the therapeutic community as best they can

The purpose of treatment is to
acquire skills, engage
in adaptive behavior, and not engage in maladaptive behavior; the role of people in treatment is to acquire skills and change their behavior

Rehabilitation is unlike treatment; the purpose is to overcome disabilities that are barriers toward realizing one's own wishes and aspirations; the role of all participants is to identify goals and work toward them

Role of person receiving services

The patient’s role is to follow the directions
of the doctor (psychiatrist).

The role of people in treatment is to participate in the therapeutic community as best they can.

The role of people in treatment is to acquire skills and change their behavior.

The role of all participants is to identify goals and work toward them.

Methods of assessment and intervention

Psychiatric diagnosis
is the key to
treatment; once the disease is diagnosed
its causes and symptoms are the targets of medical treatment

The role of assessment is to determine
specific problems that
prevent
a person from participating in the social community;
the problems are
overcome by
designing the social environment so as to enhance effective participation

Assessment identifies specific skill deficits
and maladaptive behaviors; skills are acquired through training
and designing the environment to
provide appropriate incentives and disincentives

Assessment identifies the person's desires and aspirations and relevant barriers to achieving them; rehabilitation imparts the means to overcome the barriers

Organizational principles and decision-making practices

Services are
organized so as
to be directed
by the doctor (psychiatrist), who makes all key
decisions about what treatment will be provided and how

The key organizational principles are those
that define the therapeutic community and its processes; key decisions are made by the community as
much as possible

Decisions are driven by functional analysis of behavior and its environmental concommitants;
services are
organized to enhance collection
of behavioral and environmental data

Services are organized around the rehabilitation client; decisions
are driven by the client's choices