‘Effective’ at What? On Effective Intervention in Serious Mental Illness

  • Susan C.C. HawthorneEmail author
  • Anne Williams-Wengerd
Original Article


The term “effective,” on its own, is honorific but vague. Interventions against serious mental illness may be “effective” at goals as diverse as reducing “apparent sadness” or providing housing. Underexamined use of “effective” and other success terms often obfuscates differences and incompatibilities in interventions, degrees of effectiveness, key omissions in effectiveness standards, and values involved in determining what counts as “effective.” Yet vague use of such success terms is common in the research, clinical, and policy realms, with consequences that negatively affect the care offered to individuals experiencing serious mental illness. A pragmatist-oriented solution to these problems suggests that when people use success terms, they need to explain and defend the goals and supporting values embedded in the terms, asking and answering the questions, “Effective at what? For whom? How effective? And why that goal?” Practical and epistemic standards for effectiveness will likely remain plural for good reasons, but each standard should be well explained and well justified.


Serious mental illness Treatment Effectiveness Psychology Psychiatry Clinical social work 



  1. 1.
    Abassi, M., Majdzadeh, R., Zali, A., Karimi, A., & Akrami, F. (2018). The evolution of public health ethics frameworks: Systematic review of moral values and norms in public health policy. Medicine, Health Care and Philosophy, 21(3), 387–402.CrossRefGoogle Scholar
  2. 2.
    American Psychological Association Presidential Task Force on Evidence-Based Practice. (2006). Evidence-based practice in psychology. American Psychologist, 61(4), 271–285. Scholar
  3. 3.
    Andresen, R., Caputi, P., & Oades, L. G. (2010). Do clinical outcome measures assess consumer-defined recovery? Psychiatry Research, 177, 309–317.CrossRefGoogle Scholar
  4. 4.
    Arts, B., Simons, C. J., Drukker, M., & van Os, J. (2013). Antipsychotic medications and cognitive functioning in bipolar disorder: Moderating effects of COMT Val108/158 Met genotype. BMC Psychiatry, 13, 63. Scholar
  5. 5.
    Bauer, M., El-Khalili, N., Datto, C., Szamosi, J., & Eriksson, H. (2010). A pooled analysis of two randomised, placebo-controlled studies of extended release quetiapine fumarate adjunctive to antidepressant therapy in patients with major depressive disorder. Journal of Affective Disorders, 127(1–3), 19–30. Scholar
  6. 6.
    Berg, H., & Slaattelid, R. (2017). Facts and values in psychotherapy—A critique of the empirical reduction of psychotherapy within evidence-based practice. Journal of Evaluation in Clinical Practice, 23, 1075–1080.CrossRefGoogle Scholar
  7. 7.
    Cabassa, L. J., Ezell, J. M., & Lewis-Fernandez, R. (2010). Lifestyle interventions for adults with serious mental illness: A systematic literature review. Psychiatric Services (Washington, DC), 61(8), 774–782. Scholar
  8. 8.
    Carlier, I. V. E., Meuldijk, D., Van Vliet, I. M., Van Fenema, E., Van der Wee, N. J. A., & Zitman, F. G. (2012). Routine outcome monitoring and feedback on physical or mental health status: Evidence and theory. Journal of Evaluation in Clinical Practice, 18(1), 104–110.CrossRefGoogle Scholar
  9. 9.
    Carpenter, J. (2002). Mental health recovery paradigm: Implications for social work. Health and Social Work, 27(2), 86–94.CrossRefGoogle Scholar
  10. 10.
    Cartwright, N., & Stegenga, J. (2011). A theory of evidence for evidence-based policy. In P. Dawid, T. Vasiliki, & M. Vasiliki (Eds.), Evidence, Inference and Enquiry (pp. 289–319, Proceedings of the British Academy, Vol. 171): Oxford University Press/British Academy.Google Scholar
  11. 11.
    Chamberlin, J., & Rogers, J. A. (2006). Planning a community-based mental health system, perspective of service recipients. In L. Davidson, C. Harding, & L. Spaniol (Eds.), Recovery from severe mental illnesses: Research evidence and implications for practice (Vol. 2, pp. 405–413). Boston: Center for Psychiatric Research.Google Scholar
  12. 12.
    Cipriani, A., Furukawa, T. A., Salanti, G., Chaimani, A., Atkinson, L. Z., Ogawa, Y., et al. (2018). Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: A systematic review and network meta-analysis. The Lancet, 391(10128), 1357–1366.CrossRefGoogle Scholar
  13. 13.
    Davidson, L., & Roe, D. (2007). Recovery from versus recovery in serious mental illness: One strategy for lessening confusion plaguing recovery. Journal of Mental Health, 16(4), 459–470.CrossRefGoogle Scholar
  14. 14.
    Davidson, L., Harding, C., & Spaniol, L. (2005). Preface. In L. Davidson, C. Harding, & L. Spaniol (Eds.), Recovery from severe mental illnesses: Research evidence and implications for practice (Vol. 1, p. xix). Boston: Center for Psychiatric Rehabilitation.Google Scholar
  15. 15.
    Davidson, L., O’Connell, M., Tondora, J., Staeheli, M., & Evans, A. C. (2005). Recovery in serious mental illness: Paradigm shift or shibboleth? In L. Davidson, C. Harding, & L. Spaniol (Eds.), Recovery from severe mental illnesses: Research evidence and implications for practice (Vol. 1, pp. 5–26). Boston: Center for Psychiatric Rehabilitation.Google Scholar
  16. 16.
    Douglas, H. E. (2016). Science, policy, values: Exploring the nexus. Perspectives on Sciene, 24(5), 475–480.CrossRefGoogle Scholar
  17. 17.
    Drake, R. E., Bond, G. R., Goldman, H. H., Hogan, M. F., & Karakus, M. (2016). Individual placement and support services boost employment for people with serious mental illnesses, but funding is lacking. Health Affairs; Chevy Chase, 35(6), 1098–1105.CrossRefGoogle Scholar
  18. 18.
    Draper, H. (2000). Anorexia nervosa and respecting a refusal of life-prolonging therapy: A limited justification. Bioethics, 14(2), 120–133.CrossRefGoogle Scholar
  19. 19.
    El-Khalili, N., Joyce, M., Atkinson, S., Buynak, R. J., Datto, C., Lindgren, P., et al. (2010). Extended-release quetiapine fumarate (quetiapine XR) as adjunctive therapy in major depressive disorder (MDD) in patients with an inadequate response to ongoing antidepressant treatment: A multicentre, randomized, double-blind, placebo-controlled study. International Journal of Neuropsychopharmacology, 13(7), 917–932. Scholar
  20. 20.
    Essock, S. M., Goldman, H. H., Van Tosh, L., Anthony, W. A., Appell, C. R., Bond, G. R., et al. (2006). Evidence-based practices: Setting the context and responding to concerns. In L. Davidson, C. Harding, & L. Spaniol (Eds.), Recovery from severe mental illnesses: Research evidence and implications for practice (Vol. 2, pp. 414–434). Boston: Center for Psychiatric Rehabilitation.Google Scholar
  21. 21.
    Frese, F. J., III, Jonathan, S., Kress, K., & Vogel-Scibilia, S. (2006). Integrating evidence-based practices and the recovery model. In L. Davidson, C. Harding, & L. Spaniol (Eds.), Recovery from severe mental illnesses: Research evidence and implications for practice (Vol. 2, pp. 375–390). Boston: Center for Psychiatric Research.Google Scholar
  22. 22.
    Garcia, A. M. (2010). What does “work” mean? Reopening the debate about clinical significance. Clinical Psychology: Science and Practice, 17(1), 48–51.Google Scholar
  23. 23.
    Green, C. A., Estroff, S. E., Yarborough, B. J. H., Spofford, M., Solloway, M. R., Kitson, R. S., et al. (2014). Directions for future patient-centered and comparative effectiveness research for people with serious mental illness in a learning mental health care system. Schizophrenia Bulletin, 40(Suppl 1), S1–S94.PubMedGoogle Scholar
  24. 24.
    Gupta, M. (2013). Psychiatry and evidence-based psychiatry: A distinction with a difference. Philosophy, Psychiatry, and Psychology, 19(4), 309–312.Google Scholar
  25. 25.
    Hawthorne, S., & Ihlan, A. (2018). Rethinking civil commitment: The radical resources of the ethics of care. Public Philosophy Journal. Scholar
  26. 26.
    Insel, T. R. (2016). The anatomy of NIMH funding. Accessed 16 December 2016.
  27. 27.
    Institute of Medicine: Division of Health Promotion and Disease Prevention. (1992). The second fifty years: Promoting health and preventing disability. In R. L. Berg & J. S. Cassells (Eds.), National Academy Press.Google Scholar
  28. 28.
    Ioannidis, J. P. A. (2008). Effectiveness of antidepressants: An evidence myth constructed from a thousand randomized trials? Philosophy, Ethics, and Humanities in Medicine, 3(1), 14.CrossRefGoogle Scholar
  29. 29.
    Jacobson, N., & Curtis, L. (2006). Recovery as policy in mental health services: Strategies emerging from the states. In L. Davidson, C. Harding, & L. Spaniol (Eds.), Recovery from severe mental illness: Research evidence and implications for practice (Vol. 2, pp. 358–374). Boston: Center for Psychiatric Rehabilitation.Google Scholar
  30. 30.
    Jacobson, N. S., Roberts, L. J., Berns, S. B., & McGlinchey, J. B. (1999). Methods for defining and determining the clinical significance of treatment effects: Description, application, and alternatives. Journal of Consulting and Clinical Psychology, 67(3), 300–307.CrossRefGoogle Scholar
  31. 31.
    Joint Commission on Mental Illness and Health. (1961). Action for mental health; final report, 1961. New York: Basic Books.Google Scholar
  32. 32.
    Kessler, R. C., Chiu, W. T., Demler, O., Merikangas, K. R., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 617–627. Scholar
  33. 33.
    Khandaker, G. M., Gandamaneni, P. K., Dibben, C., Cherukuru, S., Cairns, P., & Manaan, K. R. (2013). Evaluating care pathways for community psychiatry in England: A qualitative study. Journal of Evaluation in Clinical Practice, 19(2), 289–303.CrossRefGoogle Scholar
  34. 34.
    Kincaid, H., Dupre, J., & Wylie, A. (Eds.). (2007). Value-free science? Ideals and illusions. Oxford: Oxford University Press.Google Scholar
  35. 35.
    Kravitz, R. L., Duan, N., & Braslow, J. (2004). Evidence-based medicine, heterogeneity of treatment effects, and the trouble with averages. THe Milbank Quarterly, 82(4), 661–687.CrossRefGoogle Scholar
  36. 36.
    Krimsky, S. (2003). Science in the private interest: Has the lure of corporate profit corrupted biomedical research?. Lanham: Rowman & Littlefield.Google Scholar
  37. 37.
    Lambert, M. J., & Ogles, B. M. (2009). Using clinical significance in psychotherapy outcome research: The need for a common procedure and validity data. Psychotherapy Research, 19(4–5), 493–501. Scholar
  38. 38.
    Larsen-Barr, M. (2016). Experiencing antipsychotic medication: From first prescriptions to attempted discontinuation, dissertation. Auckland: University of Auckland.Google Scholar
  39. 39.
    Leucht, S., Winter-van Rossum, I., Heres, S., Arango, C., & Fleischhacker, W. W. (2015). The optimization of treatment and management of schizophrenia in Europe (OPTiMiSE) trial: Rationale for its methodology and a review of the effectiveness of switching antipsychotics. Schizophrenia Bullettin, 41(3), 549–558.CrossRefGoogle Scholar
  40. 40.
    Little, M., Lipworth, W., Gordon, J., Markham, P., & Kerridge, I. (2012). Values-based medicine and modest foundationalism. Journal of Evaluation in Clinical Practice, 18(5), 1020–1026.CrossRefGoogle Scholar
  41. 41.
    Longino, H. E. (1990). Science as social knowledge: Values and objectivity in scientific inquiry. Princeton, NJ: Princeton University Press.Google Scholar
  42. 42.
    Longino, H. E. (2002). The fate of knowledge. Princeton, NJ: Princeton University Press.CrossRefGoogle Scholar
  43. 43.
    Mead, S., & Copeland, M. E. (2005). What recovery means to us: Consumers’ perspectives. In L. Davidson, C. Harding, & L. Spaniol (Eds.), Recovery from severe mental illnesses: Research evidence and implications for practice (Vol. 1). Boston: Center for Psychiatric Rehabilitation.Google Scholar
  44. 44.
    Morlino, M., Calento, A., Pannone, G., Ventrella, G., & Schiavone, V. (2009). Systematic reviews to support evidence-based psychiatry: What about schizophrenia? Journal of Evaluation in Clinical Practice, 15(6), 1025–1028. Scholar
  45. 45.
    Morrison, L. J. (2005). Talking back to psychiatry: The psychiatric consumer/survivor/ex-patient movement (New Approaches in Sociology: Studies in Social Inequality, Social Change, and Social Justice, N. Naples, Ed.). New York: Routledge.Google Scholar
  46. 46.
    National Institute of Mental Health. (2017). Mental illness. Accessed 17 September 2018.
  47. 47.
    Network, H. V. (2015). Hearing voices network. Accessed 17 September 2018.
  48. 48.
    Nys, T. R. V., & Nys, M. G. (2006). Psychiatry under pressure: Reflections on psychiatry’s drift towards a reductionist biomedical conception of mental illness. Medicine, Health Care and Philosophy, 9(1), 107–115.CrossRefGoogle Scholar
  49. 49.
    Oaks, D. W. (2011). The moral imperative for dialogue with organizations of survivors of coerced psychiatric human rights violations. In T. W. Kallert, J. E. Mezzich, & J. Monahan (Eds.), Coercive treatment in psychiatry: Clinical, legal and ethical aspects (pp. 187–211). Chichester/Hoboken, NJ: Wiley/Blackwell.Google Scholar
  50. 50.
    Padgett, D. K., Stanhope, V., Henwood, B. F., & Stefanic, A. (2011). Substance use outcomes among homeless clients with serious mental illness: Comparing housing first with treatment first programs. Community Mental Health Journal, 47, 227–232.CrossRefGoogle Scholar
  51. 51.
    Paul, G. (1967). Strategy of outcome research in psychotherapy. Journal of Consulting Psychology, 31(2), 109–118.CrossRefGoogle Scholar
  52. 52.
    Payne, M. (2016). Modern social work theory (4th ed.). New York: Oxford University Press.Google Scholar
  53. 53.
    Pickersgill, M. D. (2014). Debating DSM-5: Diagnosis and the sociology of critique. Journal of Medical Ethics, 40(8), 521–525. Scholar
  54. 54.
    Reardon, S. (2017). US mental-health agency’s push for basic research has slashed support for clinical trials. Nature, 546(7658), 339.CrossRefGoogle Scholar
  55. 55.
    Reznek, L. (1991). The philosophical defence of psychiatry (Philosophical Issues in Science, ed. W. H. Newton-Smith). London: Routledge.Google Scholar
  56. 56.
    Robotham, D., Wykes, T., Rose, D., Doughty, L., Strange, S., Neale, J., et al. (2016). Service user and carer priorities in a biomedical research centre for mental health. Journal of Mental Health, 25(3), 185–188.CrossRefGoogle Scholar
  57. 57.
    Rog, D. J. (2005). The evidence on supported housing. In L. Davidson, C. Harding, & L. Spaniol (Eds.), Recovery from severe mental illnesses: Research evidence and implications for practice (Vol. 1, pp. 358–376). Boston: Center for Psychiatric Rehabilitation.Google Scholar
  58. 58.
    Shearer-Underhill, C., & Marker, C. (2010). The use of the number needed to treat (NNT) in randomized clinical trials in psychological treatment. Clinical Psychology: Science and Practice, 17(1), 41–47.Google Scholar
  59. 59.
    Sisti, D. A., Segal, A. G., & Emanuel, E. J. (2015). Improving long-term psychiatric care: Bring back the asylum (Historical Article). JAMA, 313(3), 243–244. Scholar
  60. 60.
    Solomon, M. (2015). Making medical knowledge. Oxford: Oxford University Press.CrossRefGoogle Scholar
  61. 61.
    Stettin, B., Geller, J., Ragosta, K., Cohen, K., & Ghowrwal, J. (2014). Mental health commitment laws: A survey of the states. Arlington, VA: Treatment Advocacy Center.Google Scholar
  62. 62.
    Tanenbaum, S. J. (2005). Evidence-based practice as mental health policy: Three controversies and a caveat. Health Affairs (Millwood), 24(1), 163–173. Scholar
  63. 63.
    Tanenbaum, S. J. (2008). Perspectives on evidence-based practice from consumers in the US public mental health system. Journal of Evaluation in Clinical Practice, 14, 699–706.CrossRefGoogle Scholar
  64. 64.
    Vanheule, S., & Devisch, I. (2014). Mental suffering and the DSM-5: A critical review. Journal of Evaluation in Clinical Practice, 20, 975–980.CrossRefGoogle Scholar
  65. 65.
    Wijsbek, H. (2012). ‘To thine own self be true’: On the loss of integrity as a kind of suffering. Bioethics, 26(1), 1–7.CrossRefGoogle Scholar
  66. 66.
    Yanos, P. T., Barrow, S. M., & Tsemberis, S. (2004). Community integration in the early phase of housing among homeless persons diagnosed with severe mental illness: Successes and challenges. Community Mental Health Journal, 40(2), 133–150.CrossRefGoogle Scholar

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© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Philosophy DepartmentSt. Catherine UniversitySt. PaulUSA
  2. 2.Psychology DepartmentSt. Catherine UniversitySt. PaulUSA

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