The International Journal of Psychosocial Rehabilitation
 

What’s in a name: “Serious”, “Severe”, and
 “Severe and Persistent”
 

Kenneth T. Kinter
Rutgers University




Citation:
Kinter  K.T.  (2017)     What’s in a name: “Serious”, “Severe”, and "Serious and Persistent".
 
International Journal of Psychosocial Rehabilitation. Vol 21 (1) 52-54



Author Note: Kenneth T. Kinter, Department of Psychiatric Rehabilitation and Counseling Professions, Rutgers University.
 Correspondence concerning this article should be addressed to Kenneth T. Kinter, Rutgers – SHRP, Department of Psychiatric Rehabilitation and Counseling Professions, 1776 Raritan Road, Scotch Plains, NJ 07076. Contact:
ken.kinter@rutgers.edu

Abstract
This paper discusses the origins and use of the terms “serious mental illness”, “severe mental illness”, and severe and persistent mental illness”. It makes an argument against the interchangeability of these terms, as each term has inherent strengths and weaknesses. The article suggests that the language of describing people with mental illness is ever-changing but encourages authors to use consistent language and to consider using language that describes the specific population they are discussing (e.g. people with mental illness, people with psychiatric disabilities).
           
Keywords:
serious mental illness, severe mental illness, severe and persistent mental illness.




Introduction:

In my first job for the University of Medicine and Dentistry of New Jersey (now Rutgers University) in 2004, I worked supporting two doctors with their presentations on helping people with mental illness. The first doctor consistently used the term “serious mental illness” and the second consistently used the term “severe mental illness”. After their talks, I asked them what the difference was between these terms and they didn’t know. In subsequent research, I have found that these terms are sometimes used interchangeably; sometimes one is a subset of the other and at other times they are used in opposition to each other. The purpose of this paper is to discuss the use of the terms “severe and persistent mental illness” (SPMI), “severe mental illness” and “serious mental illness” (SMI) and to continue the ongoing discussion about the various terms used to describe people with psychiatric disabilities.

All of these terms were an effort to move away from the use of the term “chronic mental illness”, which was common in the 1970’s. An example of this was the National Plan for the Chronically Mentally Ill developed during the Carter Administration (Goldman & Grob, 2006). The term “chronic” often doesn’t have a specific time frame although two years has been commonly used as a guideline. The term chronic is also often incorrectly used as a negative prognosis, rather than a statement of illness duration.

The term “serious mental illness” came from the ADAMHA Reorganization Act of 1992 and was created so that mental health providers could apply for federal funding (Insel, 2013). This definition described a person “hav(ing) a diagnosable mental, behavioral, or emotional disorder … that has resulted in functional impairment which substantially interferes with or limits one or more major life activities…All of these disorders have episodic, recurrent, or persistent features; however, they vary in terms of severity (italics mine) and disabling effects” (Federal Record, 1993). These disorders were ascertained by an interview with a non-clinician and were diagnosis specific, including mood disorders, anxiety disorders, substance use disorders, antisocial personality disorder, and several psychotic disorders.


In 1993, the National Institute of Mental Health described severe mental illness as possessing a psychiatric diagnosis, disability, and duration, including psychoses, mania, autism, and depressive and anxiety disorders with qualifiers. SAMHSA (1996) added a 12-month prevalence of psychosis, lifetime prevalence if left untreated, and hospitalization or use of “major psychotropic medications” (p. 60). SAMHSA defined severe mental illness as a subset of serious mental illness without a clear boundary. Almost immediately, the terms “severe” and “serious” began being used interchangeably, to capture largely the same phenomenon, namely disabling, and usually psychotic mental illnesses. SAMHSA (2016) even cautioned about the use of the acronym ‘SMI’, due to its use to refer to both serious and severe mental illness.


The term “severe and persistent” mental illness also arose from a desire to move away from the term “chronic” mental illness. The Carter Commission of 1978 encouraged this change in terminology (Goldman and Grob, 2006). The goal with this term was to capture mental illnesses of 1) certain diagnoses (particularly non-organic psychoses and personality disorders); 2) certain duration; and 3) causing a level of disability or impairment in functioning (Parabiaghi et al., 2006). SAMHSA (2016) went on to state that “although all severe and persistent illness may be serious, not all serious mental illness may be severe or persistent” (pg. 1).


There are multiple problems with the aforementioned terms and the context in which they are used. Making the terms diagnosis-specific implies that everyone with a “serious or severe” diagnosis (e.g. Schizophrenia) is more ill than everyone with a non-designated illness (e.g. Borderline Personality Disorder). This contributes to the stigma attenuated to certain diagnoses. The term ‘persistent’ shares the same problem with the term “chronic” in that it not only refers to history of illness but also implies future functioning with a negative tone. Much like the term “chronic”, “persistent” is also difficult to quantify.
 
The term “severe and persistent mental illness” has the advantage of capturing both the intensity and consistency of mental illnesses. It also parallels the DSM-5 diagnosis of Intellectual Disability, which utilizes severity over “serious”ness (APA, 2013). “Severe and persistent” mental illness also holds up better when looking at its obverse. The opposite of severe and persistent mental illness would be ‘mild and episodic’, whereas the opposite of “serious” would be “non-serious?” (BlueCross 2016) “Whimsical”? I would hate to tell people with diagnoses that don’t meet the “SMI” criteria that their diagnoses are not “serious”. There is a difficulty that “persistent” may still imply future impairment, when that is not certain.


 Language both informs and is informed, meaning it communicates both what we know and what we don’t yet know. We are in a field torn between a desire to maintain consistency in our terminology, even if it is technically incorrect (e.g. Schizophrenia) and changing diagnostic terms in order to make them more accurate at the risk of causing confusion (e.g. Manic Depression to Bipolar Disorder). Language is also imperfect, as no word completely captures the experience of one person, let alone everyone who shares that experience. This imperfection necessitates that language is also evolutionary; the terms ‘moron’, ‘idiot, and ‘imbecile’ were acceptable terms in the field of intellectual disabilities in the past but are clearly not now. As we learn more about Psychiatric Rehabilitation, we experience the limitations of the terms of past knowledge. It is interesting to note that even the diagnostic nomenclature of the DSM is being challenged by R-DoC and HiTOP, for example. Perhaps the most common diagnostic terms in our field may be approaching their “shelf life”.

The linguistic challenge occurs when referring to a subgroup of “people with mental illness” who are institutionalized or unable to function independently. It is easy to use the blanket term “people with mental illness”. It is less so to divide that group to specify people with psychiatric disabilities or people who are unable to fulfill important roles in their lives due to mental illness. Does disability refer strictly to impairment in work or in all major life roles? And does it refer to past or present ability? Does it refer to people with sporadic disabilities or those who have more consistent periods of disability?

 
Reflecting our desire to be taken seriously as a science, I believe it is not helpful to describe the same thing with different, interchangeable terms. I would also question if what we are actually referring to is a level of disability due to mental illness rather than a selection of diagnoses, for example “people with psychiatric disabilities”. The original intent of such terms as “serious”, “severe”, and “severe and persistent” mental illness was to secure funds for people who were unable to work or care for themselves in the community. The resulting term should reflect that and be consistent.


The goal of this article is to encourage researchers and authors in the field of Psychiatric Rehabilitation and related fields to reassess the term(s) they use for describing people with psychiatric disabilities. Pick one term that best fits the intended population; strive to create new language which is not punitive, and reflects on what we are still learning about mental illness and recovery. For myself, I will stay with “people with mental illness” as a general term and “people with psychiatric disabilities” when referring to people who cannot work or fulfill other life roles due to mental illness. That is, until something better comes along
.



References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
BlueCross BlueShield of Illinois. (2016). Serious vs. non-serious mental illness Retrieved from: http://www.bcbsil.com/provider/standards/serious_vs_non_serious.html.
Federal Register Volume 58 No. 96 published Thursday May 20, 1993, pages 29422-29425.
Goldman, H. H., & Grob, G. N. (2006). Defining ‘mental illness’ in mental health policy. Health Affairs, 25(3), 737-749.
Insel, T. (2013). Director’s Blog: Getting Serious About Mental Illnesses. Retrieved from: http://www.nimh.nih.gov/about/director/2013/getting-serious-about-mental-illnesses.shtml.
Parabiaghi, A., Bonneto, C., Ruggeri, M., Lasalvia, A., & Leese, M. (2006). Severe and  persistent mental illness: a useful definition for prioritizing community-based  mental health service interventions. Social Psychiatry and Psychiatric Epidemiology, 41(6), 457–463.
Substance Abuse and Mental Health Services Administration (SAMHSA). (1996).Mental Health, United States, 1996. Rockville, MD: Center for Mental Health          Services, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services.
Substance Abuse and Mental Health Services Administration (SAMHSA). (2016).Behind the term: Serious mental illness. Rockville, MD: Center for Mental Health       Services, Substance Abuse and Mental Health Services Administration, U.S.  Department of Health and Human Services.

 


 


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