Treatment works. A generation of research has led to this inescapable conclusion.
A vast body of literature, including complete textbooks, chapters,
and aggressive public and professional education campaigns, fully explicates
this positive message (Geriatric Psychiatry Alliance, 1997; Niederehe
& Schneider, 1998; Salzman, 1998). Yet, among ourselves, we are generally
less positive about the impact of our treatments on our patients' lives. We
will agree that most patients do pretty well most of the time on most treatments.
But we will also agree that this is not nearly good enough and that
much more needs to be learned about how treatments work.
What, in particular, don't we know as well as we would like? Why do
treatments rarely work as well in practice as they do in clinical trials? Why
are the approaches to treatment that are studied in research settings rarely
the ones that are used in practice? Does treatment enhance functioning?
Does early treatment predict a more favorable response? How can we
keep people well once they have been made well? What approaches
should be used for the treatment-resistant patient?
These are the sorts of questions that are raised within the context of
what has been called a public health model of treatment (Lebowitz & Harris,
1998). These are questions we cannot yet answer as well as we would
like, however, largely because the direction and culture of treatment
research has been determined by a more narrowly defined regulatory
model (Leber & Davis, 1998). This regulatory model has been the dominant
force shaping treatment research in the past, and we will explore
some of its limitations below