Serious mental illness (SMI) affects 5.4 percent of the U.S. adult population each year, but only about 15 percent receive proper medication, counseling and community integration interventions, according to research in the Journal of Public Health (Vol. 92, No. 1). The other 25 percent who are treated at all receive high doses of medication that reduce their symptoms--but also compromise their life functioning and fail to address underlying problems.

However, encouragingly, awareness is growing about behavioral add-ons and alternatives to medication that allow many people with such diseases as schizophrenia and bipolar disorder to recover and live normal lives. For example, President Bush's New Freedom Commission on Mental Health recommended that SMI treatment should refocus on helping people recover and live as contributing members of a community. Psychologists have been instrumental in bringing about such expansion beyond medicine-centric treatment, notes Richard H. Hunter, PhD, chair of APA's Committee for the Advancement of Professional Practice Task Force on Serious Mental Illness and Severe Emotional Disturbance.

"Over the last 30 years there's been tremendous improvements in psychological interventions working with people with serious mental illness," he says. "And psychologists are at the forefront of that. We've contributed to programs that are helping people change their behavior instead of just suppressing symptoms."

In particular, a number of treatment programs are drawing on the work of psychologists Gordon Paul, PhD, of the University of Houston, and Robert Lentz, PhD, a private consultant in Champaign, Ill., who in the 1970s developed a social learning method of rehabilitation. The method encourages patients to learn and demonstrate social skills that allow them to function in a community.

Programs using the social learning approach teach outpatient clients coping skills, catch and tackle problems early, and even treat the most severely ill patients. Here's a sampling of how some of them put such techniques into action.

Community supports

The U.S. military veterans who receive SMI outpatient services from the Errera Community Care Center in West Haven, Conn., get more than medication and psychotherapy; they receive services provided by nurses, occupational therapists, social workers and psychologists custom-tailored to such needs as finding a place to live and a job, maintaining sobriety or even just figuring out a reason to get up in the morning.

The center, part of the U.S. Department of Veterans Affairs, focuses particularly on function and rehabilitation and less so on pathology. Veterans join peer groups within the center that help veterans re-engage in a social environment and connect with others who face similar problems, like drug addiction and mood disorders, says social worker Laurie Harkness, PhD, who directs the program.

The center provides customized services for veterans with various levels of need; some are facing depression and may need a moderate amount of help finding the right medication, counseling and a social group to engage with. Others face more serious problems like post-traumatic stress disorder, substance abuse and homelessness and could need a range of services from help complying with job demands to close monitoring of a complex medication regimen.

Under the center's interdisciplinary and unusually comprehensive case-management system, the veteran and his or her staff clinician partner to devise a plan that builds on veterans' goals and strengths--commonalities of all social learning approaches--and helps them compensate for the negative effects of SMI, says psychologist Anne Labowitz Klee, PhD, director of the psychosocial rehabilitation fellowship program at the center.

Take the example of a Persian Gulf War veteran who came into Errera with major depression after attempting suicide: The center's team worked with psychiatrists to ensure he had the right medications, set up counseling sessions with psychologists and arranged for him to join a group of veterans who met daily to discuss their experiences and what gives them hope. Through those coordinated interventions, a year later the veteran's depression was in remission and he was leading a group meeting for fellow veterans.

"The people we work with, like this veteran, are going to need to take their meds, but that's only the start," says Klee. "People are going to need many more services and experiences to make themselves truly well."

That's particularly true for veterans in Errera's Mental Health Intensive Case Management Program, which takes in those with long histories of inpatient psychiatric treatment. Through intense counseling, medication monitoring, community engagement and help with everyday tasks like buying groceries and paying rent, the program helps veterans stay stable and out of hospitals. Klee says staff members even visit clients at their homes or at their favorite diner, if that's what it takes to support them.

"If they need help remembering how to take their medication, we'll be there with them at home reminding them exactly what they need to do," Harkness explains. "If they need help grocery shopping so they'll be able to take care of themselves in the future, we'll go with them and show them how to buy what they need."

Veterans also participate in peer support groups that are monitored by staff members but run by rehabilitated clients. Center "graduates" also tap a transition program called the Community Reintegration Program, in which staff keep tabs on clients through frequent check-ins, maintaining the veterans' peer group meetings and linking them with community resources, Harkness says.

Pinpointing problems

Community intervention and consistent support strategies also work in populations with more serious mental illnesses--the kind that keep clients in inpatient facilities like the University of Nebraska's Community Transition Program, a 55-bed inpatient facility.

However, because inpatient populations include people with long histories of confinement and more serious illnesses than those at an outpatient center, the program has developed a system that tailors treatments to patients' more complicated needs, says psychologist William Spaulding, PhD, program director. Indeed, by using varied assessment methods including everything from neuropsychological tests to personality assessment, the Nebraska program has put an innovative twist on the social learning method.

"What's most distinctive about our program is the amount of assessment we do to identify individuals' strengths and weaknesses," Spaulding says. The program part of the Lincoln Regional Center, serves a small population of clients who are ready for rehabilitation but not yet able to live on their own.

Staff members define problems the clients face, like an inability to pay attention for long periods of time, and create goals to work toward solving the problem, Spaulding says. For example, many patients in the program have been civilly committed for offenses like abuse and may have anger-management problems. Such patients receive counseling on how to calm down when angry and staff direction, followed by positive reinforcement, on what is appropriate aggression in an argument.

Specific strategies employed by the staff include positively reinforcing good behavior like maintaining a tidy living area, counseling patients to see their illness as a set of problems they can resolve and training them in skills like cooking and cleaning, Spaulding says.

"Getting to the root of all those problems and dealing with them in a constructive manner for the client is our goal," Spaulding says. "With that sort of treatment and the skills they've learned about appropriate behavior, the client stands a good chance of being successful moving back into the community."

After a stay at the Community Transition Program, usually 10 to 12 weeks, psychologists and social workers help clients slowly transition into less restrictive environments, like group homes, and then into independent living and employment.

"Many of our discharges go to the local mental health center's case-management agency, which uses some of the same methods we do, and through that they get subsidized housing, additional help with real-world skills and continued support," Spaulding adds.

Hope for the toughest cases

But can the social learning approach work for the most severely disabled populations--those who've already spent decades in psychiatric hospitals and are considered too dangerous to mix with general populations? At Fulton State Hospital in Fulton, Miss., psychologist Anthony Menditto, PhD, and his staff are doing exactly that in a maximum-security setting.

Through a modified social learning approach that uses even more intensive structured time and positive reinforcement methods, Menditto says he's seen patients once considered hopeless become gainfully employed, contributing members of the local community.

The key to such success? Every program staff member is specially trained to consistently provide experiences that teach skills in context, like learning to eat dinner with other people in the dining hall. The staff also records their interactions with clients to assess how frequently clients get positive feedback--a way to track how well the program is meeting its goals.

There's a lot to record. Staff members establish structured therapeutic activities for 85 percent of every client's waking day, Menditto says. For example, in cognitive reshaping sessions clients slowly build up their ability to pay attention through interactive listening and watching exercises. Staff members also teach personal care skills and table manners at grooming and meal times, the logical environments to learn these skills. Developing those skills and manners is essential to one day fitting into the general population, Meditto says.

The social learning program at Fulton also uses contingency-based behavior management to provide more positive feedback and give clients the chance to make decisions about their own lives. When clients demonstrate positive behavior, like brushing their teeth at the appointed time, the staff give them a token that they can turn in for luxuries and television time.

"We engage clients, and we get them making decisions about their lives," Menditto says. "Many of these folks have been in institutions for such a long time they get used to people making decisions for them. We try to overcome that deficit by giving them choices."

Menditto relates the example of a man with schizophrenia who'd been in a traditional maximum-security facility for 15 years before Fulton. He assaulted staff members, was functionally mute, ate with his hands and neglected his hygiene--even becoming combative when staff would ask him to shower. The hospital's shaping classes improved his ability to pay attention from 90 seconds when he started to 10 minutes or more. Eventually he could interact well with other people in the program, and moved to minimum security and reconnected with his family. After about eight years in the program, he now lives in a group home and is gainfully employed as a janitor.

"When we first took him over to a new facility that had a grassy outdoor area, he froze when he stepped out into the open and felt the grass under his feet--he hadn't had that opportunity for so many years--and now he's successful on his own in the wide world," Menditto says. "It's amazing progress, which we've learned how to replicate."

Publicizing such success may help move psychosocial rehabilitation methods into prisons, Menditto adds. Indeed, there's hope that courts and correctional institutions will take note of the potential to truly rehabilitate patients, and follow suit, says former prison psychologist Thomas Fagan, PhD.

"Interdisciplinary approaches that include psychologists would be very useful at many points in the correctional system: the disciplinary process itself--where decisions are made about where felons will go--assessment within prisons to find those with mental illness disabilities and in developing the rehabilitation programs themselves," says Fagan.

Further Reading

APA's Committee for the Advancement of Professional Practice Task Force on Serious Mental Illness and Severe Emotional Disturbance outlined best practices for recovery and improved outcomes for people with serious mental illness in a grid to be used for training by treatment providers. It is available at http://www.apa.org/practice/grid.html.