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Book Forum: Positive Approaches   |    
Treatment and Rehabilitation of Severe Mental Illness
WILLIAM R. FLYNN, M.D.
Am J Psychiatry 2004;161:937-937. doi:10.1176/appi.ajp.161.5.937
View Author and Article Information
Napa, Calif.

By William D. Spaulding, Mary E. Sullivan, and Jeffrey S. Poland. New York, Guilford Publications, 2003, 386 pp., $45.00.

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The authors are two clinical psychologists and a psychiatric social worker. In this book, they have put together an enormous amount of information on the science that underlies a comprehensive view of serious mental illness and its treatment. They reviewed several hundred books and articles for this work and also draw on their own 20-year experience developing a rehabilitation program in Lincoln, Neb. They state in the beginning that they aim to integrate the insights from the scientific study of psychopathology and from rehabilitation and case formulation to form the conceptual basis of contemporary treatment and rehabilitation (p. 1).

In the first section they review the models and paradigms that have guided treatment and rehabilitation in the past. They consider that the medical model, which preceded and later succeeded the psychoanalytic one, is not adequate because it primarily addresses the neurophysiology of mental illness through pharmacotherapy. Symptom relief through the administration of medications can restore premorbid functioning to a degree and may be sufficient in some individuals, but optimal, effective, and lasting rehabilitation for most cases of schizophrenia, for example, must address all deficits in functioning. The new paradigm is integration of assessments of and interventions at the neurocognitive, social-cognitive, and sociobehavioral levels of functioning in addition to the neurophysiological.

The authors tell us that the neo-Kraepelinian system of classification as embodied by DSM is soon to follow the psychodynamic model into extinction in favor of a theory-based system that relies on hard science. The idea of understanding mental illness in terms of its deficits is not a new one, but this work lays out the investigative evidence and describes techniques and methods to design specific interventions. For me, the greatest value of this book is in the detailed discussions of the studies and experiments done by psychologists that provide the basis for their claims to a more accurate and useful understanding of symptoms and deficits. The work that neuropsychologists have been doing for the past three decades to clarify neurocognitive malfunctioning is most impressive as it is presented here. The authors discuss in detail integrated psychological therapy and cognitive enhancement therapy, two approaches to cognitive impairment in schizophrenia that are directed toward specific abilities and disabilities and that are validated in experimental as well as clinical situations (p. 147). Throughout the text there are illustrations of the interventions that flow from viewing rehabilitation from the authors’ perspective. In addition, the book has three appendixes, one of which has a prototype of a protocol for identifying problems at different levels of functioning. For example, at the sociocognitive level, the authors list and define separate problems for problem solving as well as problems causing symptoms such as mood disorders and low self-esteem for attribution. The second appendix illustrates a master rehabilitation plan in which problems are identified and given a priority rank, treatment objectives are established, and interventions are selected. The final appendix is an algorithm for treatment and rehabilitation of schizophrenia (p. 345).

The authors analyze the phenomenon of delusional thinking in the context of the interplay of the neurophysiological and cognitive domains. They contrast the cognitive-psychological concepts of attribution theory and cognitive dissonance theory with the psychodynamic way of understanding delusions, insight, and mood disturbances. They fault the medical model for stressing the limitations imposed by the illness—the "glass half empty mentality" (p. 182).

The final two chapters deal with the organizational context of treatment and rehabilitation. Again, the authors criticize the medical model as being inimical to comprehensive treatment planning. They are concerned that the psychiatrist, who is accustomed to being treatment team leader but who may know little or nothing about the finer points of neuropsychology, for example, will devalue or neglect what other disciplines have to offer to treatment and especially to rehabilitation.

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