Reconsider the definition of serious mental illness

For the most recent 60 years, and for many centuries prior, we have characterized adults with serious mental illness (also known pejoratively as SMI) in terms of deficits. With recent developments in our understanding of trauma, recovery, and health activation, we now actually have the opportunity to do much, much better; we can develop and implement strength-based approaches. The question is: Which path will we choose?

From the 1950s to the 1970s, our national definitions focused exclusively upon problem diagnoses: for example, a person with schizophrenia was called a “schizophrenic.” Thus, a person was defined solely in terms of a problem. A person’s other positive attributes, which we employ in our everyday language, such as happiness, brightness, beauty, or other human ways of characterizing people simply were not employed. In the 1980s, we came to recognize that another factor, level of functioning, was as important, if not more important, than diagnosis in characterizing peers.

However, unfortunately, rather than focusing upon positive functioning, our definitions relied upon assessment of negative functioning, with a time dimension. For example, a person was characterized as having an inability to perform instrumental activities, such as using unfamiliar transportation routes, for a one year period. These characterizations produced a community prevalence of about 2.8% of adults, and the population was commonly referred to as adults with “severe and persistent mental illness” at the time.

In the 1990s, the ADAMHA Reorganization Act of 1992 (PL 102-321) required SAMHSA to produce a new definition of adults with serious mental illness for use with the Community Mental Health Services Block Grant Program. Like the definitions used in the 1980s, the new definition relied upon diagnosis and impairment in functioning, but the duration criterion was removed. This new definition produced a community prevalence of about 5.8% of adults, and the population was called adults with “serious mental illness.”

In the early 2000s, SAMHSA began to employ a similar approach using a proxy measure for diagnosis (the Kessler K-6 Scale) with the World Health Organization Disability Assessment Scale (WHO-DAS). This approach produced a community prevalence of about 4%. Unfortunately, this is where we stand today. Also in the 2000s, our underlying understanding of mental illness has been shifting.

We now know that the preponderance of mental illness is caused by trauma, and that people can and do recover from mental illness and regain productive, happy lives in the community. We also know that self-determination is a very important tool for recovery, and that health literacy and health activation play a very large role in successful self-determination. Underlying these developments is the very often unstated principle that mental illness should be approached from a strength-based perspective. Care should address mental illness by appropriately enhancing one’s strengths.

This notion can be seen best in the two-dimensional model of health and illness. In this model, if one simply engages in illness care, this will have no impact upon enhancing health. We must do both. What would a strength-based approach look like?

Here are a few preliminary thoughts:

• First, we would stop labeling people in this population as adults with serious mental illness, a term that comes from the ADAMHA Reorganization Act of 1992.

• Second, we would approach a new characterization from the perspective of well-being, specifically, physical well-being, mental well-being, social well-being, and spiritual well-being. Well-being is a strength-based concept that currently is gaining national and international traction.

• Third, we would review all of our current practices to see if they are consistent with a strength-based approach that promotes enhanced well-being.

• Fourth, we would come to understand in practice that the dimensions of well-being are correlated. For example, enhanced social and spiritual well-being can lead to enhanced mental well-being, and vice-versa.

Such a strength-based approach is quite consistent with current efforts to promote whole person care by integrating our partial care systems: physical, mental, and social. It also is consistent with current efforts to promote health literacy and health activation, i.e., how one employs one’s strengths to mitigate illness and its effects. Finally, it is fully consistent with efforts to promote a culture of well-being in our communities and in our work places.

Clearly, it is high time to set our compass toward a new direction. I expect that we will be very pleased with what we can encounter on this refreshing new journey into the realm of well-being. We must set forth today.