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Reconsider the definition of serious mental illness

October 19, 2015
by Ron Manderscheid, PhD
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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.




Hello Ron: I always enjoy your articles and this article speaks to me. At Anne Arundel County Mental Health Agency, we widely teach Mental Health First Aid to the general public and clinicians. The Course stresses the very strengths you outline. I am happy to see someone else touting the importance of strengths that are available to the mentally challenged that are rarely put into a clinical plan.

Thanks Kate! I appreciate the confirmation you provide for this approach.

Ron, I really appreciated your post and particularly your calling attention to the fact that the preponderance of what is called "mental illness" is the result of trauma. I also appreciated that you suggested the field stop labeling people as "adults with serious mental illness." I'd like to suggest we consider going a step further, and stop using terms like "mental illness" to describe extreme mental and emotional states. Those of us with psychiatric histories would benefit if the system embraced trauma-informed approaches and moved away from illness models.

Thanks for your good words, Ron. As individuals who care about the sustainable quality of the systems transformation already underway, how might we use deliberate creativity practices to forge a new future that inspires wellbeing for all? Peer leadership development and purposeful innovation strategies can help advocate for inclusion and release of cross cultural traumas. Using an appreciative and strengths based approach about what's working is a way to begin. As we engage and activate this integrative approach at individual and systems levels how might Mindful Self Care and Systems Transformation become more directly linked. The global community converging around awareness-based change models can help guide us - is a community employing these mindful practices and Duke U recently launched an Integrative Healthcare leadership training initiative that enhances their other exemplary programs including specialized yoga and other mind-body integration practices. Https://
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Ron Manderscheid

Exec. Dir., NACBHDD and NARMH

Ron Manderscheid


Ron Manderscheid, Ph.D., serves as the Executive Director of the National Association of County...

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