Abstract
     This article examines the roles that psychologists could play in the care and treatment of those diagnosed with serious mental illness. Roles include expert diagnosis, especially for co-morbid patients, developing and evaluating psychosocial rehabilitation and recovery methods, provide empirically supported therapies, develop the next generation of psychological interventions, and, with appropriate postdoctoral training and supervised experience, function as consultative psychopharmacologists. Pathways to practice are discussed as is the importance of forming partnerships with recovered consumers of mental health services.

Key Words
     Consumers; deinstitutionalization; psychosocial rehabilitation; recovery; severe and persistent mental illness; stigma.

     Psychology is not currently a major player in the public sector care and treatment of patients suffering from serious mental illness, such as schizophrenia, bipolar disorders and major depression. This is somewhat ironic because at one time clinical psychology had defined its purview as serious psychopathology. It is also very short-sighted because in this era of cost-containment and shrinking opportunities for the practice of psychology, the care of such patients represents a potential growth area, one based on an expanded scope of practice.

     The Center for Mental health Services (CMHS, 1996), part of the U.S. Substance Abuse and Mental Health Services Administration, estimates that 5.4 million adults (2.7% of the population) have a "severe and persistent" mental illness, and that more than 3 million children and adolescents have a serious emotional disturbance that undermines their present functioning and endangers their future.

     As we all know, this large and very vulnerable population receives substandard care. Deinstitutionalization, which was conceived in the humanitarianism and the idealism of the Community Mental Health Movement of the 1960’s, has been a stark failure overall (although there have been some success stories here and there). With the clarity of 20/20 hindsight, we can see that there was insufficient investment in community-based care and psychological rehabilitation to make it work. There was also an over-reliance on psychoactive medications, which (again in retrospect) was terribly short-sighted given the lack of adequate care systems designed to prevent relapses due to non-compliance. In the end, the deinstitutionalization movement succeeded in emptying the beds of the state mental hospitals and filling the streets and jails with chronic mental patients. Indeed, an article in the New York Times described the jail as the "new mental hospital" (Butterfield, 1998).

     Having worked with this population off and on over many years I have found that many have very complex comorbidities, including (in addition to their serious mental illness) substance abuse, brain injury, post-traumatic stress disorder (PTSD, particularly among the women, many of whom have been victims of rape), and DSM IV Axis II diagnoses such as borderline personality disorder (to name some of the more common diagnoses). Also, due to the harsh lifestyle of the street that many members of this population lead, there are often untreated medical problems as well. A population this vulnerable and disabled deserves much better care than our society now offers.

     Psychologists could play a very significant role in the care of this population. Some in the mental health field promote the idea that serious mental illness is a "brain disease" and therefore treatable only by biological interventions (e.g., medications), psychiatrists have virtually abandoned this population. Furthermore, the outcome research literature strongly indicates that while psychoactive medications can suppress the symptoms of serious mental illness, psychological rehabilitation actually holds out hope for recovery (Anthony, 1993; Coursey, Alford, & Safarjan, 1997).

     The concept of recovery is really quite an important notion in that it confronts the stigmatizing stereotypes that view serious mental illness as essentially hopeless. Too often such long-term conditions as schizophrenia and bipolar disorder (to name just two) are viewed extremely pessimistically, as incurable conditions. But evidence has been accumulating that indicates that people diagnosed with serious mental illness do recover through a combination of psychotherapy, psychosocial rehabilitation, consumer?run self?help programs, and medications. The concept of "recovery" in this work involves a shift in perspective from a medical to a rehabilitative model.

     We must continue to work to change public policies and social attitudes that regard these illnesses as hopeless and thereby allow the disgraceful neglect of people who suffer from them to continue. APA has begun this process with the passage of the Resolution on Stigma and Serious Mental Illness by the APA Council of Representatives in February 1999.

     Hence, I think that we have lot to offer in the care and treatment of the seriously mentally ill patient. First of all, there is no profession better qualified than psychology to conduct the careful diagnostic assessments that would tease out the complex comorbidities that many of these individuals suffer from. Second, since psychologists have taken the lead in developing and evaluating psychological rehabilitation and recovery methods, we can surely lay claim to the role of designing, implementing and training staff members to carry out psychological rehabilitation. Third, we can provide empirically validated therapies for persons with serious mental illness. Fourth, practitioners can team up with researchers and develop the next generation of psychological interventions that might have even greater effectiveness (Bellak, Mueser, Gingerich, & Agresta, 1007; Dixon & Lehman, 1995; Linehan, Armstrong, Suarez, Allmon, & Heard, 1991)

     Fifth, we can play a larger role in the medical aspects of these patients’ lives. Ultimately, of course, we could prescribe psychoactive medications after the successful passage of prescription privilege legislation. Right now psychologists with the appropriate postdoctoral training and supervised experience can function as consultative psychopharmacologists, who, working in conjunction with primary care physicians or in some states even nurse practitioners, can provide the full spectrum of care for the seriously mentally ill patient. Our role as consultative psychopharmacologists for the seriously and persistently mentally ill population has been delineated by an APA Board of Educational Affairs Task Force on consultative psychopharmacology. Although this role has been challenged recently in several state jurisdictions (Massachusetts, Florida, and Washington, DC), the Board of Psychology in all three instances has upheld this role as part of psychologists' scope of practice.

     Finally, such an enhanced role in the care of the seriously mentally ill would go a long way toward furthering our aim of becoming the premier primary behavioral health care profession. By reaching out and responding effectively to a public health problem of this size and scope we would surely establish our credibility. Furthermore, such an expanded role is consistent with other efforts to expand the scope of practice of psychology in areas such as health care, brain injury, and the courts.

     The critical factor is going to be the development of new pathways to practice. In the care for the seriously mentally ill patient, new pathways to practice are clearly needed, based on an expanded scope of practice as outlined above. Some universities are now offering training in this area (e.g., Nova Southeastern University, Boston University, University of Maryland) but much more needs to be done. We need postdoctoral retraining programs which include training in psychological rehabilitation and consultative psychopharmacology, legislation to change archaic civil service staffing patterns where they still exist, and entrepreneurship to develop psychological delivery systems in those states that outsource mental health care.

     Psychology would also be well advised to work to develop partnerships with recovered patients. There is a growing cadre of people who have recovered from serious mental illness who can serve as invaluable allies in the recovery process. Such “consumers”, also known as "survivors of psychiatric treatment" and "ex?mental patients," are interested in collaborating with psychologists, and deeply believe from their own experiences that psychotherapy and psychosocial rehabilitation can be very beneficial. But to develop such a coalition, these consumers state clearly that psychologists must understand their perspectives on such matters as participating in their own recovery, the integration of self?help with professional services, living with a diagnosis of serious mental illness, forced treatment and its alternatives, and on the abuses that many have experienced in the mental health system (Bassman, 1997; Freese & Davis, 1997).

References
Anthony, W.A. (1993). Recovery from mental illness: The guiding vision of mental health service system in the 1990s. Psychosocial Rehabilitation Journal, 16 (4), 11-23.
Bassman, R. (1997). The mental health system: Experiences from both sides of the locked doors. Professional Psychology: Research & Practice, 28, 238-242.
Bellack, A. S., Mueser, K. E., Gingerich, S. G., & Agresta, J. (1997). Social skills training for schizophrenia. New York: Guilford Press.
Butterfield, F. (1998, March 5). By default jails become mental institutions, New York Times, pp. A1, A13.
Center for Mental Health Services (1996). Mental health, United States, 1996 Manderscheid, R. and Sonnenschein, M., (Eds.). (DHHS Publication No. SMA 96-3098). Washington, DC: U.S. Government Printing Office.
Coursey, R.D., Alford, J., & Safarjan, W. (1997). Significant advances in understanding and treating serious mental illness. Professional Psychology: Research & Practice, 28, 205-216. Dixon, L.B., & Lehman, A.F. (1995). Family interventions for schizophrenia. Schizophrenia Bulletin, 21, 631-643.
Freese, F.J., & Davis, W.W. (1997). The consumer/survivor movement, recovery and consumer professionals. Professional Psychology: Research & Practice, 28, 243-245.
Linehan, M.M., Armstrong, H.E., Suarez, A., Allmon, D., & Heard, H.L. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48, 1060-1064.

Biographical Sketch
Ronald F. Levant, Ed.D., A.B.P.P., is Recording Secretary of the American Psychological Association. He was the Chair of the APA Committee for the Advancement of Professional Practice (CAPP) from 1993-95, a member at large of the APA Board of Directors (1995-97), and APA Recording Secretary (1998-2000). He is Dean, Center for Psychological Studies, Nova Southeastern University, Fort Lauderdale, FL.

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