LETTERS
Letters from readers are wel-
come. They will be published at
the editor’s discretion as space
permits and will be subject to ed-
iting. They should not exceed 500
words with no more than three
authors and five references and
should include the writer’s tele-
phone and fax numbers and e-
mail address. Letters related to
material published in Psychiatric
Services, which will be sent to the
authors for possible reply, should
be sent to John A. Talbott, M.D.,
Editor, Psychiatric Services,
American Psychiatric Association,
1000 Wilson Boulevard, Suite
1825, MS#4 1906, Arlington, Vir-
ginia 22209-3901; fax, 703-907-
1095; e-mail, psjournal@psych.
org. Letters reporting the results
of research should be submitted
online for peer review (http://
appi.manuscriptcentral.com).
Process, Not Practice
To the Editor: William A. Anthony,
Ph.D., makes an excellent point in
the January 2003 Taking Issue (1),
“Studying Evidence-Based Process,
Not Practices.” He argues that in-
stead of studying practices and pro-
grams, one should examine “process,”
by which he means such things as
“collaborative goal setting, skills train-
ing, . . . providing environmental ac-
commodations, and coaching.” Dr.
Anthony quite correctly points out
that processes cut across programs.
He also states that program differ-
ences, when found, may have little to
do with the nominal differences un-
der study.
Can Dr. Anthony’s argument fall
anywhere but on the deaf ears of
those who fund outcome studies or
on the nodding heads of those who
provide care and treatment to per-
sons with chronic mental illnesses?
The latter group knows that what he
says is true but has little leverage to
direct funds for outcome studies. The
former cares little for process because
processes cannot be directly funded.
Furthermore, Dr. Anthony makes
402
the assumption that process studies
would have less contaminated out-
comes than studies of practices—that
is, the process under study is actually
the key variable that accounts for the
differences found in a study with ran-
dom assignment, which of course can
never be double-blind. His assump-
tion might be correct, but we don’t
know. There is no research.
So I ask you, Dr. Anthony, who is
going to fund the research you and I
would like to see? For if the research
were funded, we could get away from
many program issues, including fool-
ish arguments about the loci of care
and treatment. We would likely find
that the process and not the place
makes most of the difference.
Jeffrey L. Geller, M.D., M.P.H.
Dr. Geller is professor of psychiatry and
director of public-sector psychiatry at the
University of Massachusetts Medical
School in Worcester.
In Reply: Dr. Geller raises a very im-
portant question. In essence, are
studies of process fundable? Do the
research agencies and their peer re-
view teams concur about the rele-
vance of such studies?
I believe that process studies are
fundable, but I thought I would check
this out with some of the powers that
be at the National Institute of Mental
Health. They agree that studies of
process and outcome are important.
There are a number of current pro-
gram announcements (PAs) under
which a researcher so inclined could
apply (see www.nimh.nih.gov). I par-
ticularly like PA-01-145, entitled “Re-
search on Quality of Care for Mental
Disorders,” as a mechanism for study-
ing the relationship between process
and outcome.
However, the fundamental ques-
tion we might wish to ask ourselves is
not how these studies should be fund-
ed, but why they need to be funded?
The argument for following this line
of research needs to be made repeat-
edly and forcefully. For example, we
already have data suggesting that peo-
ple who recover from severe mental
illnesses identify their relationships
PSYCHIATRIC SERVICES ♦ http://psychservices.psychiatryonline.org ♦ March 2003 Vol. 54 No. 3
with other people as key to their re-
covery process (1). A plethora of stud-
ies in psychotherapy point to the im-
portance of process variables in
achieving therapeutic outcomes (2).
Why wouldn’t these factors be worthy
of intense study in the field of severe
mental illnesses?
Furthermore, we need to under-
stand what the person served thinks
about the helping process that he or
she experienced. Thus, when we study
the impact of the human interactive
process, let us advocate for the value of
subjective measures and qualitative
approaches. In a similar vein, process
and outcome studies need to empha-
size the outcome dimensions that the
person served believes are important,
such as meaningful roles in society,
self-efficacy, well-being, reduced lev-
els of discrimination, and minimal ia-
trogenic impacts (3).
It is up to us to present supportive
research from other fields, develop
the helping models that focus on
process, and collect and report the
data. I am convinced that study of the
helping process, rather than program
structure and program setting, is crit-
ical. Unfortunately, information and
publications about evidence-based
practices are currently being dissemi-
nated without data on the helping
process that occurs within each prac-
tice or on the process dimensions that
cut across evidence-based practices. I
would encourage Dr. Geller and oth-
er like-minded researchers—includ-
ing myself—to continue to make a
case for studying the human interac-
tive process in our field. Increased
funding will follow.
William A. Anthony, Ph.D.
References
1. Spaniol LS, Wewiorski NJ, Gagne C, et al:
The process of recovery from schizophre-
nia. International Review of Psychiatry
14:327–336, 2002
2. Norcross JC (ed): Empirically supported
therapy relationships: summary report of
the Division 29 Task Force. Psychotherapy:
Theory, Research, Practice, Training (spe-
cial issue) 38(4), 2001
3. Anthony WA, Rogers ES, Farkas M: Re-
search on evidence based practices: future
directions in an era of recovery. Communi-
ty Mental Health Journal, in press

Psychiatric Services
for People With
Mental Retardation
To the Editor: In an April 2002 re-
view of articles on special populations
that have been published in Psychi-
atric Services since 1950, Bell and
Williamson (1) drew attention to the
paucity of articles about people with
mental retardation. They reported that
no article on this topic had been pub-
lished in at least the past ten years.
That was a matter of surprise to me,
because I had been reading a series of
articles on people with mental retarda-
tion who used generic psychiatric serv-
ices when I came across two relevant
studies in Psychiatric Services.
In 1995 the journal published a
study by Patterson and colleagues (2)
that described an evaluation of a sys-
tem aimed at reducing hospitalization
of people with mental retardation in
Washington State. In 1997 Dudley
and associates (3) reported on the sat-
isfaction of patients with mental re-
tardation after they were discharged
from state psychiatric hospitals into
community placements in North Car-
olina. The criteria used by Bell and
Williamson are not clear, because
they did not include these articles in
their review.
Although I did not formally check
for other articles in Psychiatric Ser-
vices, I performed electronic and
manual searches for articles on pa-
tients with mental retardation in Psy-
chiatric Bulletin. In the United King-
dom, mental retardation was referred
to formerly as “mental handicap” and
more recently as “learning disability.”
Psychiatric Bulletin, which is pub-
lished by the Royal College of Psychi-
atrists in the United Kingdom, is the
“sister journal” of Psychiatric Ser-
vices. It publishes research reports on
treatment, administration, training,
and management of psychiatric serv-
ices. Of 1,633 articles published in
the past eight years, 42 (3 percent)
focused on people with learning dis-
abilities. This is bound to be an un-
derestimate, because letters to the
editor were counted as articles and
were not included in my search.
I hope that this letter will stimulate
PSYCHIATRIC SERVICES ♦ http://psychservices.psychiatryonline.org ♦ March 2003 Vol. 54 No. 3
trans-Atlantic interest in the much
neglected area of research on service
provision for this population, which
has higher than average needs for
mental health care.
Rob Chaplin, M.B.Ch.B.,
M.R.C.Psych.
Dr. Chaplin is a consultant in general
adult psychiatry for the Oxfordshire Men-
tal Healthcare NHS Trust in Oxford, Unit-
ed Kingdom.
References
1. Bell CC, Williamson J: Articles on special
populations published in Psychiatric Ser-
vices between 1950 and 1999. Psychiatric
Services 53:419–424, 2002
2. Patterson T, Higgins M, Dyck DG: A col-
laborative approach to reduce hospitaliza-
tion of developmentally disabled clients
with mental illness. Psychiatric Services
46:243–247, 1995
3. Dudley JR, Calhoun ML, Ahlgrim-Delzell
L, et al: A consumer satisfaction survey of
people with mental retardation and mental
illness. Psychiatric Services 48:1075–1077,
1997
In Reply: We thank Dr. Chaplin, who
correctly points out that there were
two articles about people with mental
retardation that we did not identify in
our review. Our search for articles on
special populations published over
the 50-year period entailed reviewing
the contents of each issue—a total of
about 8,000 articles. Such a manual
search is quite a chore, and we think
that our oversight is forgivable, espe-
cially when there are careful readers
like Dr. Chaplin standing by to give
constructive opinion. There were few
articles that addressed this popula-
tion, which makes the identification
of two additional articles that much
more significant.
We hasten to point out that even
with the addition of the two articles,
fewer than ten articles about people
with mental retardation were pub-
lished in the 50-year period. The au-
thors share Dr. Chaplin’s desire to
stimulate interest in service provision
for this population. We hope that our
review and his letter will generate fur-
ther exchange and publications in this
underrepresented area of research.
Carl C. Bell, M.D.
Johnny Williamson, M.D.
LETTERS
Cultural Competence
and Corporate Culture
To the Editor: In the December is-
sue, Lewis A. Opler, M.D., Ph.D., re-
views a videotape of a cultural com-
petence and diversity training pro-
gram. He writes, “Being oblivious to
this reality [cultural factors] is fraught
with as much danger as being un-
aware that psychotherapy is influ-
enced by transference and counter-
transference or that pharmacothera-
py is influenced by the cleverly craft-
ed marketing strategies of pharma-
ceutical companies.”
The cleverly crafted marketing
strategies are exquisitely depicted in
the drug advertisements displayed
throughout the December issue of
the journal. The one that caught my
eye was an advertisement for Zyprexa
on the inside cover. In addition to the
graphic visual message of the doctor
(in a white coat) extending his arm to
rescue the patient attempting to
climb out of a ravine while standing
on a large letter Z (color-coded
throughout the ad), there is an inter-
esting text, which, I believe is almost
subliminally misleading.
The narrative begins by telling us
that medication isn’t the only answer
to the treatment of mental illness.
One would think that this is a refer-
ence to additional interventions such
as psychotherapy or psychosocial re-
habilitation. But instead the text goes
on to describe how medication can
“enable a strong therapeutic alliance”
with the physician to establish a “sol-
id treatment foundation and stay on
course”—presumably to facilitate the
patient’s compliance with medication
treatment. In other words, the impor-
tance of medication as an “essential
component in the treatment of men-
tal illness” is to help the physician to
treat the patient with medication!
What is at issue here is not the role
of pharmacological interventions in
the treatment of psychiatric disor-
ders, but, as Dr. Opler emphasizes,
the need to recognize the role of cul-
tural factors that influence psychiatric
treatment—in this case corporate
culture.
Manny Wertman
403
LETTERS
Mr. Wertman is director of adult mental
health services at the Ohel Children’s
Home and Family Services in Brooklyn,
New York.
Reference
1. Opler LA: The Culture of Emotions: A Cul-
tural Competence and Diversity Training
Program. Psychiatric Services 53:1537–
1538, 2002
In Reply: I share Mr. Wertman’s con-
cerns. As APA’s leadership grapples
with the issue of how our organization
and its members should handle issues
of corporate influence, much-needed
guidelines will emerge.
One troubling indicator of corpo-
rate culture’s impact on the practice
of psychiatry is the change in our
treatment model from a truly biopsy-
chosocial integrative approach to one
in which drug treatment is empha-
sized at the expense of psychosocial
therapies. In 1981, Eduardo Castro,
Kathleen Duffy, Pedro Ruiz, Cecilia
White, and I wrote that “a self-con-
scious reaffirmation of the holistic ap-
proach in psychiatry offers psychia-
trists . . . a way to treat patients, while
offering psychiatry an opportunity to
review crises of identity . . . disen-
chantment, and pessimism” (1). More
recently, I wrote, “Recovery from a
severe mental disorder requires treat-
ment of the whole person. . . . Phar-
macotherapy is necessary but not suf-
ficient” (2).
I am an optimist: psychiatry has
risen to challenges before, and I be-
lieve we will again reject reduction-
ism—whether its cause is corporate
influence or the desire for easy an-
swers—and will rediscover the com-
plex interactions of biological, psy-
chological, and social forces that
make us as well as our patients what
and who we are.
Lewis A. Opler, M.D., Ph.D.
References
1. White CM, Opler LA, Castro E, et al: The
holistic approach and the future of psychia-
try. World Journal of Psychosynthesis 13:
19–22, 1981
2. Ehrlich H, Opler LA: Resurrection and Re-
demption: Overcoming Mental Illness and
Regaining Dignity. Baltimore, Pub-
lishAmerica, 2003

Invitation for Papers on the Theme of

the 2003 Institute on Psychiatric Services
“Access to Integrated Care” is the theme of the 2003 Institute on Psychiatric Ser-
vices to be held October 29 to November 2 in Boston. The November 2003 issue
of Psychiatric Services will be distributed to institute attendees, and the journal
invites papers to be published in that issue addressing the institute’s theme,
which is evoked in the following statements.
Integrated care means:
♦ An appreciation of the importance of a therapeutic alliance and working re-
lationship.
♦ Psychiatrists being able to provide both psychotherapy and medication as
needed.
♦ Good communication and collaboration when different members of the
team provide psychotherapy and medication.
♦ A centralized process of providing all the supports that patients may need—
such as housing, education, social support, and general health care.
♦ The provision of mental health care and other supports to incarcerated pa-
tients when they are released.
To propose a submission, please contact John A. Talbott, M.D., at psjournal@
psych.org. All papers will be peer reviewed. The deadline for submission is May
1, 2003.

404 PSYCHIATRIC SERVICES ♦ http://psychservices.psychiatryonline.org ♦ March 2003 Vol. 54 No. 3