Severe Mental Illness & Recovery (Interactive Lecture 1):
Severe Mental Illness (SMI) is typically defined through three core components:
Definition:
The National Institute of Mental Health (NIMH, 1987) defines SMI using three required criteria:
(a) Diagnosis
A major diagnosis of:
non-organic psychosis, or
a personality disorder associated with severe impairment.
(b) Duration
Problems must persist for at least 2 years.
(c) Disability
The individual must meet at least two of the five categories of functional disabilities.
Expanded Criteria Details:
(a) Diagnosis:
A major affective disorder, non-organic psychotic disorder, or a personality disorder likely to cause
chronic disability (e.g., borderline personality disorder).
(b) Duration:
Treatment history must meet one or both of the following:
Intensive psychiatric treatment more than once in a lifetime – Such as:
Crisis services, alternative home care, partial hospitalization, inpatient care...
Continuous supportive residential care (not hospitalization) long enough to significantly disrupt
normal life.
(c) Disability:
Severe, recurrent disability resulting in functional limitations in major life areas.
The person must meet at least 2/5 disability categories on a continuing or intermittent basis:
Work impairment:
Unemployed, sheltered/supportive work, or poor work history
Social support difficulties:
Cannot establish or maintain a social network
Basic daily living skills problems:
Needs help with hygiene, food preparation, or money management
, Financial dependence:
Requires public financial assistance and cannot manage it independently
Inappropriate social behavior:
Leads to intervention from mental health and/or judicial systems
“Difficult-to-Treat Patients”
1. Contextual / Social Factors
These patients often face complex social conditions that make treatment more challenging:
→ Poverty or debt
→ Low socioeconomic status
→ Unemployment
→ Homelessness
→ Criminal or inappropriate social behaviour
These conditions: increase vulnerability, reduce stability, and limit access to consistent care.
2. Dual Diagnosis (Comorbidity)
Many “difficult-to-treat” patients present with multiple overlapping problems, such as:
Substance use occurring alongside mental illness
Childhood trauma, abuse, or attachment difficulties
Additional depressive or anxiety symptoms
This combination of psychiatric symptoms + substance use + trauma makes care more complex and less
responsive to standard treatment pathways.
3. Why They’re Seen as “Too Complex to Treat”
Research shows that these patients often face:
→ Lack of structured treatment
→ Limited cooperation or engagement
→ Poor alliance with professionals
→ Pessimistic attitudes, dependency, or demoralization
→ Systemic barriers (e.g., lack of organizational support)
Together, these factors create a picture of patients who require more flexible, personalized, long-term
approaches rather than standard protocols.
Historical Perspective: From Chronicity to Cure
,Institutional Era:
For decades, SMI was viewed as inherently chronic and deteriorating.
Patients were placed in institutional settings where the priority was safety and containment, not
recovery.
Deinstitutionalization:
The introduction of antipsychotic medications in the 1960s allowed many individuals to leave institutions.
This gave rise to the belief that SMI could be treated medically and led to widespread
deinstitutionalization.
The Rise of the Disease Model:
The success of medication established the disease model as the dominant framework:
Mental illness as an internal pathology causing symptoms, which can be treated — ideally cured —
through targeted interventions.
The Disease Model (“Cure Paradigm”)
Core Idea:
The disease model views mental illness as an internal medical disease that causes symptoms.
Because of this, treatment is oriented toward cure rather than long-term support.
Key assumptions:
Severe mental illness is treated primarily with drug-based interventions.
Using the term disease automatically brings a medical, cure-focused mindset.
Nomothetic logic:
Symptoms are explained by an underlying disease mechanism.
The goal is to identify universal disease states.
If a person has disease Y, it is assumed to cause symptoms x, y, and z.
Treating the underlying disease should lead to symptom disappearance.
The term “disease model” also carries a medical discourse of cure.
Ontology:
A mental disorder is conceptualized as a causal disease process within the person.
Symptoms are seen as external signs of this hidden cause.
, Treatment goal: eliminate the underlying disease.
Outcome logic: if symptoms decrease, the cause is assumed to have been treated.
End result: eliminated symptoms = no disease = “cured.”
Epistemology (How We Gain Knowledge):
The cure paradigm builds knowledge by isolating and describing symptoms clearly, then assigning them
to diagnoses.
a) Symptom description as central
Emphasis on clear, objective symptom listing.
This leads to “cookbook psychiatry” (treatment recipes based on symptoms).
Diagnoses are treated as isolated categories.
When multiple clusters of symptoms occur → labeled comorbidity.
b) Comorbidity
When a person experiences more than one type of psychiatric suffering, the cure paradigm
interprets this as having multiple diseases simultaneously.
Comorbidity: symptom clusters are separated into different diagnoses, even if they are
connected in the person’s lived experience.
c) Evidence-Based Treatments (EBT/EST)
Evidence is assumed to be context-independent (same across all patients).
Treatments are manualized, often resulting in a one-size-fits-all approach.
Cure in the Disease Model:
a) Focus on eliminating the causal disease
Assumes symptoms are malleable because they come from an internal cause (Westen et al., 2004):
Causal: A causes B
Nomothetic: A always causes B
Predictable: If A happens, B will happen
b) Symptom reduction as primary outcome
Success is defined by symptom severity dropping below a statistical cut-off.
Reduced symptoms = reduced disease activity.
c) Manualized treatment
Step-by-step protocols for symptom reduction.
Each diagnosis has its assigned treatment package.
Goal is to minimize variability → treatment becomes context-independent.
Limitations of Symptom-Based Diagnosis (DSM):
Severe Mental Illness (SMI) is typically defined through three core components:
Definition:
The National Institute of Mental Health (NIMH, 1987) defines SMI using three required criteria:
(a) Diagnosis
A major diagnosis of:
non-organic psychosis, or
a personality disorder associated with severe impairment.
(b) Duration
Problems must persist for at least 2 years.
(c) Disability
The individual must meet at least two of the five categories of functional disabilities.
Expanded Criteria Details:
(a) Diagnosis:
A major affective disorder, non-organic psychotic disorder, or a personality disorder likely to cause
chronic disability (e.g., borderline personality disorder).
(b) Duration:
Treatment history must meet one or both of the following:
Intensive psychiatric treatment more than once in a lifetime – Such as:
Crisis services, alternative home care, partial hospitalization, inpatient care...
Continuous supportive residential care (not hospitalization) long enough to significantly disrupt
normal life.
(c) Disability:
Severe, recurrent disability resulting in functional limitations in major life areas.
The person must meet at least 2/5 disability categories on a continuing or intermittent basis:
Work impairment:
Unemployed, sheltered/supportive work, or poor work history
Social support difficulties:
Cannot establish or maintain a social network
Basic daily living skills problems:
Needs help with hygiene, food preparation, or money management
, Financial dependence:
Requires public financial assistance and cannot manage it independently
Inappropriate social behavior:
Leads to intervention from mental health and/or judicial systems
“Difficult-to-Treat Patients”
1. Contextual / Social Factors
These patients often face complex social conditions that make treatment more challenging:
→ Poverty or debt
→ Low socioeconomic status
→ Unemployment
→ Homelessness
→ Criminal or inappropriate social behaviour
These conditions: increase vulnerability, reduce stability, and limit access to consistent care.
2. Dual Diagnosis (Comorbidity)
Many “difficult-to-treat” patients present with multiple overlapping problems, such as:
Substance use occurring alongside mental illness
Childhood trauma, abuse, or attachment difficulties
Additional depressive or anxiety symptoms
This combination of psychiatric symptoms + substance use + trauma makes care more complex and less
responsive to standard treatment pathways.
3. Why They’re Seen as “Too Complex to Treat”
Research shows that these patients often face:
→ Lack of structured treatment
→ Limited cooperation or engagement
→ Poor alliance with professionals
→ Pessimistic attitudes, dependency, or demoralization
→ Systemic barriers (e.g., lack of organizational support)
Together, these factors create a picture of patients who require more flexible, personalized, long-term
approaches rather than standard protocols.
Historical Perspective: From Chronicity to Cure
,Institutional Era:
For decades, SMI was viewed as inherently chronic and deteriorating.
Patients were placed in institutional settings where the priority was safety and containment, not
recovery.
Deinstitutionalization:
The introduction of antipsychotic medications in the 1960s allowed many individuals to leave institutions.
This gave rise to the belief that SMI could be treated medically and led to widespread
deinstitutionalization.
The Rise of the Disease Model:
The success of medication established the disease model as the dominant framework:
Mental illness as an internal pathology causing symptoms, which can be treated — ideally cured —
through targeted interventions.
The Disease Model (“Cure Paradigm”)
Core Idea:
The disease model views mental illness as an internal medical disease that causes symptoms.
Because of this, treatment is oriented toward cure rather than long-term support.
Key assumptions:
Severe mental illness is treated primarily with drug-based interventions.
Using the term disease automatically brings a medical, cure-focused mindset.
Nomothetic logic:
Symptoms are explained by an underlying disease mechanism.
The goal is to identify universal disease states.
If a person has disease Y, it is assumed to cause symptoms x, y, and z.
Treating the underlying disease should lead to symptom disappearance.
The term “disease model” also carries a medical discourse of cure.
Ontology:
A mental disorder is conceptualized as a causal disease process within the person.
Symptoms are seen as external signs of this hidden cause.
, Treatment goal: eliminate the underlying disease.
Outcome logic: if symptoms decrease, the cause is assumed to have been treated.
End result: eliminated symptoms = no disease = “cured.”
Epistemology (How We Gain Knowledge):
The cure paradigm builds knowledge by isolating and describing symptoms clearly, then assigning them
to diagnoses.
a) Symptom description as central
Emphasis on clear, objective symptom listing.
This leads to “cookbook psychiatry” (treatment recipes based on symptoms).
Diagnoses are treated as isolated categories.
When multiple clusters of symptoms occur → labeled comorbidity.
b) Comorbidity
When a person experiences more than one type of psychiatric suffering, the cure paradigm
interprets this as having multiple diseases simultaneously.
Comorbidity: symptom clusters are separated into different diagnoses, even if they are
connected in the person’s lived experience.
c) Evidence-Based Treatments (EBT/EST)
Evidence is assumed to be context-independent (same across all patients).
Treatments are manualized, often resulting in a one-size-fits-all approach.
Cure in the Disease Model:
a) Focus on eliminating the causal disease
Assumes symptoms are malleable because they come from an internal cause (Westen et al., 2004):
Causal: A causes B
Nomothetic: A always causes B
Predictable: If A happens, B will happen
b) Symptom reduction as primary outcome
Success is defined by symptom severity dropping below a statistical cut-off.
Reduced symptoms = reduced disease activity.
c) Manualized treatment
Step-by-step protocols for symptom reduction.
Each diagnosis has its assigned treatment package.
Goal is to minimize variability → treatment becomes context-independent.
Limitations of Symptom-Based Diagnosis (DSM):
