Community Mental Health Journal Volume 3, Number 1, Spring, 1967
THE COMPETENCE CRITERION FOR MENTAL HEALTH PROGRAMS LESLIE PHILLIPS, PH.D.*
goals need the most careful consideration and must be articulated far more precisely than they have been to date. The intent of community mental health programs is in particular need of clarification. No one definition of mental health has found wide acceptance; there is no generally accepted theory as to the nature of mental disorder; and there are no established criteria by which the effectiveness of mental health programs may be assessed. This paper is directed to the last issue: What criteria shall serve to test the adequacy of programs in the field of mental Mental health programs, which form one health? Freeman and Sherwood (1965) have of the major social welfare movements of urged the development of an ~r our times, are now in a period of rapid ex- model" by which the quality of services is pansion. They already account for a large judged according to their success in bringproportion of each state's budget and make ing about desired changes, i.e., having the use of substantial funds drawn from the desired impact. These authors contrast their federal treasury. The recent growth of these model with the more traditional emphasis programs expresses a national commitment on the extent and quality of services rento improved mental health services for all dered, in which "good service" ia defined citizens, along with augmented support for merely as that which is offered in a proeducation, enlarged services for the men- fessional manner by a qualified person who tally retarded, and the current campaign in turn is supervised by a qualified superagainst the effects of poverty. Inevitably, visor. Yet, as Freeman and Sherwood obthese programs compete for large but not serve, services are only the means for the inexhaustible funds and for experienced fulfillment of program goals; the ultimate personnel, who will always remain in short test of a program is not the procedures it in. supply. yokes but the degree to which its goals are It is difficult to set any exact figure on the achieved. The "services-rendered" criterion is apcost of all these services but currently several billion dollars annually are being ex- plied by nearly all those who set policy for, pended on them nationally. The newly pro- or who carry out programs, in the field of posed system of community mental health mental health: legislators and administracenters will raise these expenditures sub- tors at the state level, the courts, psychiastantially. Allocation of such large public trists, and other types of mental health prosums to the fulfillment of any objective, fessionals at the local level. Nevertheless, however worthy, becomes a major social is- they often differ drastically as to the yardsue even for a country as wealthy as the stick by which these services are to be measUnited States. Because all these programs ured. Administrators will judge hospital cannot be implemented without limit, their services by the cost per occupied bed, while Mental health programs are ordinarily assessed in terms of the extent of services rendered and the professional level of staff. These criteria do not permit an accurate judgment of the value of these services. It is proposed that measures of the effectiveness and cost of such programs are required. The relative contributions of an index of therapeutic impact versus a measure of improvement in "social competence" are discussed. It is concluded that the competence criterion is more objective and quantifiable in nature and more directly relevant to publicly supported mental health programs.
*Dr. Phillips is Professor of Psychology and Research Professor in The Institute of Human Sciences, Boston College, Chestnut Hill, Mass. He was formerly with Worcester State Hospital and continues to he a consultant there. The position presented in this paper is based on work supported by the Dementia Praecex Research Project, Worcester State Hospital, Worcester, Mass., and a research grant (MH-06359) from the National Institute of Mental Health, United States Public Health Service.
73
74
THE COMMUNITYMENTALHEALTHJOURNAL
the courts will evaluate services according to whether they can institutionalize for observation all those whose behavior is not understood, such as that of alcoholics, drug addicts, or homosexuals. For these public authorities, mental institutions exist to diagnose and house in some humane fashion those persons whose behavior is deviant but not antisocial. In contrast, mental health professionals try to provide therapeutic services for their patients and call insistently for additional funds to pay for new positions, programs, and buildings. In the provision and use of mental health services, public authorities respond to social pressures, therapists to the intrapsychic needs of their clients. Latent in the services-rendered criterion is the impact criterion. All those persons who set policy for mental health programs, as well as those who administer them, are concerned with the value of these services and the degree to which they fulfill their objectives. The courts and public administrators use an uncomplicated criterion of success. For the courts, satisfactory services have been rendered when the offender is housed; administrators ask, in addition, at what unit cost. The therapist's criterion by which services are to be judged is far more complex. He is not satisfied with simply housing his clients, nor is he particularly concerned with the cost of services. He is committed to the proposition that therapy will lead to some desirable (although not clearly specified) end. It seems fair to represent psychiatry and its allied disciplines as committed to the fol. lowing propositions: (1) The primary goal of mental health services is to diminish the impact of mental and emotional disorder on the psychological make-up of the individual client. (2) Relief from intrapsychic difficulties will have the consequence of enhancing his participation in the life of the commu. nity. (3) There is a need to increase the extent and intensity of psychiatric services available to the general public. THE CmTEmONor THERAPEUTICEFFICACY Certain issues are raised by adoption of these propositions. The first problem is con-
cerned with devising some criterion of therapeutic success. Its measurement is dependent on the clarity with which the pathological process itself is defined and measured. Unhappily, no generally accepted definition of psychopathology is available, and no adequate criterion for its classification and measurement has been devised. Clinicians vary in their assumptions as to the nature of disorder, treating it variously as a consequence of genetic dysfunction, of psychological trauma, or of social disor. ganization. Clinicians often differ on the diagnosis of disorder and differ, too, in their judgments of its severity. Further, there is a surprising dearth of studies on the effects of therapy. It has been shown that drugs can alleviate some of the more dramatic expressions of psychopathology, but there are no reports of full cures in psychiatric disorder based only on the use of drugs. The results of psycho. therapeutic intervention are even more ambiguous. The evidence is ambiguous as to whether psychotherapy has significant im. pact on pathological forms of behavior (Eysenck, 1961; Rogers & Dymond, 1954), although many clients express a subjective sense of improvement in their condition. In the face of the enormous sums invested in mental health services over the last century and more, our knowledge of the effects of the various forms of therapeutic intervention is startlingly deficient. Relatively little attention has been shown for the need to evaluate the adequacy of the various types of therapy, perhaps because the efforts of professional staffs have concentrated on the provision of services rather than on any test of their efficacy. Certain assumptions inhere in the use of therapeutic efficacy as the criterion by which mental health services are to be judged. First, it implies that the "patient" is the victim of some form of "illness." His role in the development of that illness is minimized, while his recovery is largely de. pendent on the skill of his therapist. This assumption determines a therapist-patient relationship that demands active control by the practitioner and a state of passive co. operation on the part of the client.
LESLIE PHILLIPS
75
Adoption of the criterion of therapeutic 1961; Zigler & Phillips, 1960; Zigler & success as the test of mental health pro- Phillips, 1961b; Zigler & Phillips, 1962). grams strongly reinforces the dominance of When the enhancement of competence the medical discipline in this field. Even becomes a primary program commitment, those nonmedical professionals who insist mental disorder itself may be viewed as only on their right to independent practice have one of many forms of inappropriate response largely adopted the framework of thought to deficient coping potential. Other possible and even the vocabulary of medicine. They inadequate responses to societal expectaspeak of mental health and illness, about tions include delinquency, alcoholism, their patients, of therapy, and prognosis. prostitution, and poverty itself. In this To view mental disorder as a form of ill- sense, deviant behavior is not an illness/that ness and to adopt a criterion of therapeutic has attacked the individual but is an expresefficacy underscores the uniqueness of men. sion of the total person as he actively, altal health programs as a form of social ac- though ineffectually, attempts to come to tion. This position fosters the current isola- terms with his environment. Persons who tion of these programs from newly develop- behave inappropriately need help in order ing services in the fields of education, men- to develop means for effective participation tal retardation, and poverty and reinforces in the life of the community. When the present public policy that provides sepa- "pathology" is viewed in this fashion, all rate funding for these programs. Yet the social action programs are directed at the victims of poor education programs, retar- development of individual social compedation, mental disorder, and poverty are tence. This proposition serves to unify the found clustered together in pockets of eco- objectives of the presently independent sonomic and cultural deprivation, and high cial action programs and makes clear why rates of other forms of social pathology, government has an unambiguous responsisuch as drug and alcoholic addiction and de- bility for their maintenance. The developlinquency and crime, also appear in these ment of social competence is as much the areas. Consequently, the wisdom of this concern of society as is the education of its policy is open to question. young or of new work skills among the unemployed. THE CRITERIONOF COMPETENCE
It is possible to devise a quite different criterion of success for mental health programs. This is the degree to which the person learns to resolve his life problems and to cope effectively with those expectations imposed by society according to his age and sex. A person's social competence (Phillips, in press) can be evaluated in two areas of behavior: the impersonal world of technological and socioeconomic activities, in which the person acquires an education, develops work skills, and insures the wellbeing of himself and his dependents; and the world of personal relationships, which requires an acceptance of responsibility both for one's fate and that of others-whether of one's immediate dependents or of one's community. The social competence index has proved of significance in predicting the form and outcome of psychiatric disorder (Phillips, 1953; Phillips & Zigler,
EVALUATIONOF PROGRAMS
Adoption of a competence rather than a therapeutic criterion transfers the locus of professional concern from the intrapsychic to the psychosocial sphere of client behavior. It demands a precise differentiation of the nature of competence and the development of objective criteria for its measurement. The writer and his colleagues have been engaged in this task for over a decade (Broverman, 1964; Broverman, Jordan, & Phillips, 1960; Feffer & Phillips, 1953; Fine, Fulkerson, & Phillips, 1955; Fowler, 1957; Gerard & Phillips, 1953; Lane, 1955; Phillips, 1953; Phillips, 1962; Phillips, 1966; Phillips, in press; Phillips & Cowitz, 1953; Phillips & Zigler, 1961; Smith & Phillips, 1959; Zigler & Phillips, 1960; Zigler & Phillips, 1961a; Zigler & Phillips, 1961b; Zigler & Phillips, 1962). It has been found related to performance un-
76
THE COMMUNITYMENTAL HEALTH JOUItNAL
adjustment and social attainment. J. abnorm. soc. Psychol., 1955, 50, 33-35. FOWLER,R. Psychopathology and social adequacy: a Rorschaeh developmental study. Unpublished doctoral dissertation, Pennsylvania State Uni. versity, 1957. FREEMAN,H. E., & SHERwooD,C. C. Research in large-scale intervention programs, f. soc. Issues, 1965, 21, 11-28. GARMEZY,N., & RODNICK,E. Premorbid adjustment and performance in schizophrenia../, nerv. ment. D/s., 1959, 129, 450--466. GERARD, D. L., & PHILLIPS, L. Relation of social attainment to psychological and adrcnorcortical reactions to stress. Arch. Neurol. Psychiat., 1953, 69, 350-354. GRACE,N. B. A developmental comparison of word usage with structural aspects of perception and social adjustment. Unpublished doctoral dissertation, Duke University, 1956. I~NE, J. E. Social effectiveness and developmental level. J. Pers., 1955, 23, 274-284. PHILLIPS, L. Case history data and prognosis in schizophrenia. J. nerv. ment. Dis., 1953, 6, 515-525. PHILLIPS, L. Social competence and the nature of psychopathology. In A. Wellek (Ed.), Proceedings of the Sixteenth International Congress of Psychol. ogy. Amsterdam, The Netherlands: NorthHolland Publishing Co., 1962. Pp. 847-848. PHILLIPS, L. Social competence, the process-reactive distinction and the nature of mental dis. order. In P. Hoch & J. Zubin (Eds.), Psychopathology of schizophrenia. New York: Grune & Stratton, 1966. Pp. 471-481. PHILLIPS,L. The severe disorders. In P. London & D. Rosenhan (Eds.), Abnormal psychology, in press. PHILLIPS, L., & CowIrz, B. Social attainment and reactions to stress. Jour. Pers., 1953, 22, 270-283. PHILLIPS, L., & ZIGLER,E. Social competence: the action-thought parameter and vicariousness in normal and pathological behaviors. Y. abnorm. soc. Psychol., 1961, 63, 137-146. Rocr.Rs, C., & DYMOND,R. Psychotherapy andpersonality change. Chicago: University of Chicago Press, 1954. SMITH,L. C., Jr., & PHILLIPS,L. Social effectiveness REFERENCES and developmental level in adolescence. J. PePs., 1959, 27, 240-249. BROVERMAN,D. M. Generality and behavioral corZIGLES,E., & PHILLIPS,L. Social effectiveness and relates of cognitive styles. J. consult. Psychol., symptomatic behaviors. J. abnorm, soc. Psychol., 1964, 28, 487-500. 1960, 61, 231-238. BROVERMAN,D. M., JORDAN,E. J., JR., & PHILLIPS, L. Achievement motivation in fantasy and be- ZIGLER,E., & PHILLIPS,L. Case history data and psychiatric diagnosis. J. consult. Psychol., 1961a havior. J. abnorm, see. Psychol., 1960, 60, 374-378. 25, 458. EYS~.NCK, H. ]. The effects of psychotherapy. In ZIGLEP~E., & PHILLIPS,L. Social competence and H. J. Eysenck (Ed.), Handbook ofabnormalpsyoutcome in psychiatric disorder. J. abnorm, soc. chology. New York: Basic Books, 1961. Pp. Psychol., 1961b, 63, 264-271. 697-725. FEFFER, M., & PHILLIPS,L. Social attainment and ZIGLEa, E., & PmLLIPS, L. Social competence and performance under stress. Y. Pers., 1953, 22,284the process-reactive distinction in psycho297. pathology. ?. abnorm, soc. Psychol., 1962, 65, FINE, H. L, FULKERSON,S. C., & PHgLLIPS,L. Mal. 215-222.
der conditions of experimental stress (Feffee & Phillips, 1953; Gerard & Phillips, 1953) and achieved level of psychological development (Grace, 1956; Lane, 1955; Smith & Phillips, 1959). Others have reNted competence level to achievement motivation (Broverman, Jordan, & Phillips, 1960), the response to threat (Garmezy & Rodnick, 1959), and to various aspects of cognitive performance (Broverman, 1964). Assessment of program impact requires the consideration of at least two aspects of program performance: its effectiveness and the efficiency with which it is carried out. In order to evaluate effectiveness, explicit program objectives must be spelled out in terms that are subject to measurement. In this light, the competence criterion is superior to the therapeutic criterion, for it is more amenable to direct, objective, and quantitative assessment. Program efficiency may be defined in terms of the cost of a given unit of successful achievement, for example, an increase in earning power measured in terms of additional dollars of income per year. Adoption of the competence criterion as an alternative to any index of change in pathological state encourages the develop. ment of alternate forms of community mental health programs in addition to the present primary commitment to psychothera. peutic and pharmacological procedures. These programs should be free to compete in the market place and to be judged ac. cording to their relative contributions to community mental health, measured in terms of their efficacy and efficiency.
THE COMPETENCE CRITERION FOR MENTAL HEALTH PROGRAMS LESLIE PHILLIPS, PH.D.*
goals need the most careful consideration and must be articulated far more precisely than they have been to date. The intent of community mental health programs is in particular need of clarification. No one definition of mental health has found wide acceptance; there is no generally accepted theory as to the nature of mental disorder; and there are no established criteria by which the effectiveness of mental health programs may be assessed. This paper is directed to the last issue: What criteria shall serve to test the adequacy of programs in the field of mental Mental health programs, which form one health? Freeman and Sherwood (1965) have of the major social welfare movements of urged the development of an ~r our times, are now in a period of rapid ex- model" by which the quality of services is pansion. They already account for a large judged according to their success in bringproportion of each state's budget and make ing about desired changes, i.e., having the use of substantial funds drawn from the desired impact. These authors contrast their federal treasury. The recent growth of these model with the more traditional emphasis programs expresses a national commitment on the extent and quality of services rento improved mental health services for all dered, in which "good service" ia defined citizens, along with augmented support for merely as that which is offered in a proeducation, enlarged services for the men- fessional manner by a qualified person who tally retarded, and the current campaign in turn is supervised by a qualified superagainst the effects of poverty. Inevitably, visor. Yet, as Freeman and Sherwood obthese programs compete for large but not serve, services are only the means for the inexhaustible funds and for experienced fulfillment of program goals; the ultimate personnel, who will always remain in short test of a program is not the procedures it in. supply. yokes but the degree to which its goals are It is difficult to set any exact figure on the achieved. The "services-rendered" criterion is apcost of all these services but currently several billion dollars annually are being ex- plied by nearly all those who set policy for, pended on them nationally. The newly pro- or who carry out programs, in the field of posed system of community mental health mental health: legislators and administracenters will raise these expenditures sub- tors at the state level, the courts, psychiastantially. Allocation of such large public trists, and other types of mental health prosums to the fulfillment of any objective, fessionals at the local level. Nevertheless, however worthy, becomes a major social is- they often differ drastically as to the yardsue even for a country as wealthy as the stick by which these services are to be measUnited States. Because all these programs ured. Administrators will judge hospital cannot be implemented without limit, their services by the cost per occupied bed, while Mental health programs are ordinarily assessed in terms of the extent of services rendered and the professional level of staff. These criteria do not permit an accurate judgment of the value of these services. It is proposed that measures of the effectiveness and cost of such programs are required. The relative contributions of an index of therapeutic impact versus a measure of improvement in "social competence" are discussed. It is concluded that the competence criterion is more objective and quantifiable in nature and more directly relevant to publicly supported mental health programs.
*Dr. Phillips is Professor of Psychology and Research Professor in The Institute of Human Sciences, Boston College, Chestnut Hill, Mass. He was formerly with Worcester State Hospital and continues to he a consultant there. The position presented in this paper is based on work supported by the Dementia Praecex Research Project, Worcester State Hospital, Worcester, Mass., and a research grant (MH-06359) from the National Institute of Mental Health, United States Public Health Service.
73
74
THE COMMUNITYMENTALHEALTHJOURNAL
the courts will evaluate services according to whether they can institutionalize for observation all those whose behavior is not understood, such as that of alcoholics, drug addicts, or homosexuals. For these public authorities, mental institutions exist to diagnose and house in some humane fashion those persons whose behavior is deviant but not antisocial. In contrast, mental health professionals try to provide therapeutic services for their patients and call insistently for additional funds to pay for new positions, programs, and buildings. In the provision and use of mental health services, public authorities respond to social pressures, therapists to the intrapsychic needs of their clients. Latent in the services-rendered criterion is the impact criterion. All those persons who set policy for mental health programs, as well as those who administer them, are concerned with the value of these services and the degree to which they fulfill their objectives. The courts and public administrators use an uncomplicated criterion of success. For the courts, satisfactory services have been rendered when the offender is housed; administrators ask, in addition, at what unit cost. The therapist's criterion by which services are to be judged is far more complex. He is not satisfied with simply housing his clients, nor is he particularly concerned with the cost of services. He is committed to the proposition that therapy will lead to some desirable (although not clearly specified) end. It seems fair to represent psychiatry and its allied disciplines as committed to the fol. lowing propositions: (1) The primary goal of mental health services is to diminish the impact of mental and emotional disorder on the psychological make-up of the individual client. (2) Relief from intrapsychic difficulties will have the consequence of enhancing his participation in the life of the commu. nity. (3) There is a need to increase the extent and intensity of psychiatric services available to the general public. THE CmTEmONor THERAPEUTICEFFICACY Certain issues are raised by adoption of these propositions. The first problem is con-
cerned with devising some criterion of therapeutic success. Its measurement is dependent on the clarity with which the pathological process itself is defined and measured. Unhappily, no generally accepted definition of psychopathology is available, and no adequate criterion for its classification and measurement has been devised. Clinicians vary in their assumptions as to the nature of disorder, treating it variously as a consequence of genetic dysfunction, of psychological trauma, or of social disor. ganization. Clinicians often differ on the diagnosis of disorder and differ, too, in their judgments of its severity. Further, there is a surprising dearth of studies on the effects of therapy. It has been shown that drugs can alleviate some of the more dramatic expressions of psychopathology, but there are no reports of full cures in psychiatric disorder based only on the use of drugs. The results of psycho. therapeutic intervention are even more ambiguous. The evidence is ambiguous as to whether psychotherapy has significant im. pact on pathological forms of behavior (Eysenck, 1961; Rogers & Dymond, 1954), although many clients express a subjective sense of improvement in their condition. In the face of the enormous sums invested in mental health services over the last century and more, our knowledge of the effects of the various forms of therapeutic intervention is startlingly deficient. Relatively little attention has been shown for the need to evaluate the adequacy of the various types of therapy, perhaps because the efforts of professional staffs have concentrated on the provision of services rather than on any test of their efficacy. Certain assumptions inhere in the use of therapeutic efficacy as the criterion by which mental health services are to be judged. First, it implies that the "patient" is the victim of some form of "illness." His role in the development of that illness is minimized, while his recovery is largely de. pendent on the skill of his therapist. This assumption determines a therapist-patient relationship that demands active control by the practitioner and a state of passive co. operation on the part of the client.
LESLIE PHILLIPS
75
Adoption of the criterion of therapeutic 1961; Zigler & Phillips, 1960; Zigler & success as the test of mental health pro- Phillips, 1961b; Zigler & Phillips, 1962). grams strongly reinforces the dominance of When the enhancement of competence the medical discipline in this field. Even becomes a primary program commitment, those nonmedical professionals who insist mental disorder itself may be viewed as only on their right to independent practice have one of many forms of inappropriate response largely adopted the framework of thought to deficient coping potential. Other possible and even the vocabulary of medicine. They inadequate responses to societal expectaspeak of mental health and illness, about tions include delinquency, alcoholism, their patients, of therapy, and prognosis. prostitution, and poverty itself. In this To view mental disorder as a form of ill- sense, deviant behavior is not an illness/that ness and to adopt a criterion of therapeutic has attacked the individual but is an expresefficacy underscores the uniqueness of men. sion of the total person as he actively, altal health programs as a form of social ac- though ineffectually, attempts to come to tion. This position fosters the current isola- terms with his environment. Persons who tion of these programs from newly develop- behave inappropriately need help in order ing services in the fields of education, men- to develop means for effective participation tal retardation, and poverty and reinforces in the life of the community. When the present public policy that provides sepa- "pathology" is viewed in this fashion, all rate funding for these programs. Yet the social action programs are directed at the victims of poor education programs, retar- development of individual social compedation, mental disorder, and poverty are tence. This proposition serves to unify the found clustered together in pockets of eco- objectives of the presently independent sonomic and cultural deprivation, and high cial action programs and makes clear why rates of other forms of social pathology, government has an unambiguous responsisuch as drug and alcoholic addiction and de- bility for their maintenance. The developlinquency and crime, also appear in these ment of social competence is as much the areas. Consequently, the wisdom of this concern of society as is the education of its policy is open to question. young or of new work skills among the unemployed. THE CRITERIONOF COMPETENCE
It is possible to devise a quite different criterion of success for mental health programs. This is the degree to which the person learns to resolve his life problems and to cope effectively with those expectations imposed by society according to his age and sex. A person's social competence (Phillips, in press) can be evaluated in two areas of behavior: the impersonal world of technological and socioeconomic activities, in which the person acquires an education, develops work skills, and insures the wellbeing of himself and his dependents; and the world of personal relationships, which requires an acceptance of responsibility both for one's fate and that of others-whether of one's immediate dependents or of one's community. The social competence index has proved of significance in predicting the form and outcome of psychiatric disorder (Phillips, 1953; Phillips & Zigler,
EVALUATIONOF PROGRAMS
Adoption of a competence rather than a therapeutic criterion transfers the locus of professional concern from the intrapsychic to the psychosocial sphere of client behavior. It demands a precise differentiation of the nature of competence and the development of objective criteria for its measurement. The writer and his colleagues have been engaged in this task for over a decade (Broverman, 1964; Broverman, Jordan, & Phillips, 1960; Feffer & Phillips, 1953; Fine, Fulkerson, & Phillips, 1955; Fowler, 1957; Gerard & Phillips, 1953; Lane, 1955; Phillips, 1953; Phillips, 1962; Phillips, 1966; Phillips, in press; Phillips & Cowitz, 1953; Phillips & Zigler, 1961; Smith & Phillips, 1959; Zigler & Phillips, 1960; Zigler & Phillips, 1961a; Zigler & Phillips, 1961b; Zigler & Phillips, 1962). It has been found related to performance un-
76
THE COMMUNITYMENTAL HEALTH JOUItNAL
adjustment and social attainment. J. abnorm. soc. Psychol., 1955, 50, 33-35. FOWLER,R. Psychopathology and social adequacy: a Rorschaeh developmental study. Unpublished doctoral dissertation, Pennsylvania State Uni. versity, 1957. FREEMAN,H. E., & SHERwooD,C. C. Research in large-scale intervention programs, f. soc. Issues, 1965, 21, 11-28. GARMEZY,N., & RODNICK,E. Premorbid adjustment and performance in schizophrenia../, nerv. ment. D/s., 1959, 129, 450--466. GERARD, D. L., & PHILLIPS, L. Relation of social attainment to psychological and adrcnorcortical reactions to stress. Arch. Neurol. Psychiat., 1953, 69, 350-354. GRACE,N. B. A developmental comparison of word usage with structural aspects of perception and social adjustment. Unpublished doctoral dissertation, Duke University, 1956. I~NE, J. E. Social effectiveness and developmental level. J. Pers., 1955, 23, 274-284. PHILLIPS, L. Case history data and prognosis in schizophrenia. J. nerv. ment. Dis., 1953, 6, 515-525. PHILLIPS, L. Social competence and the nature of psychopathology. In A. Wellek (Ed.), Proceedings of the Sixteenth International Congress of Psychol. ogy. Amsterdam, The Netherlands: NorthHolland Publishing Co., 1962. Pp. 847-848. PHILLIPS, L. Social competence, the process-reactive distinction and the nature of mental dis. order. In P. Hoch & J. Zubin (Eds.), Psychopathology of schizophrenia. New York: Grune & Stratton, 1966. Pp. 471-481. PHILLIPS,L. The severe disorders. In P. London & D. Rosenhan (Eds.), Abnormal psychology, in press. PHILLIPS, L., & CowIrz, B. Social attainment and reactions to stress. Jour. Pers., 1953, 22, 270-283. PHILLIPS, L., & ZIGLER,E. Social competence: the action-thought parameter and vicariousness in normal and pathological behaviors. Y. abnorm. soc. Psychol., 1961, 63, 137-146. Rocr.Rs, C., & DYMOND,R. Psychotherapy andpersonality change. Chicago: University of Chicago Press, 1954. SMITH,L. C., Jr., & PHILLIPS,L. Social effectiveness REFERENCES and developmental level in adolescence. J. PePs., 1959, 27, 240-249. BROVERMAN,D. M. Generality and behavioral corZIGLES,E., & PHILLIPS,L. Social effectiveness and relates of cognitive styles. J. consult. Psychol., symptomatic behaviors. J. abnorm, soc. Psychol., 1964, 28, 487-500. 1960, 61, 231-238. BROVERMAN,D. M., JORDAN,E. J., JR., & PHILLIPS, L. Achievement motivation in fantasy and be- ZIGLER,E., & PHILLIPS,L. Case history data and psychiatric diagnosis. J. consult. Psychol., 1961a havior. J. abnorm, see. Psychol., 1960, 60, 374-378. 25, 458. EYS~.NCK, H. ]. The effects of psychotherapy. In ZIGLEP~E., & PHILLIPS,L. Social competence and H. J. Eysenck (Ed.), Handbook ofabnormalpsyoutcome in psychiatric disorder. J. abnorm, soc. chology. New York: Basic Books, 1961. Pp. Psychol., 1961b, 63, 264-271. 697-725. FEFFER, M., & PHILLIPS,L. Social attainment and ZIGLEa, E., & PmLLIPS, L. Social competence and performance under stress. Y. Pers., 1953, 22,284the process-reactive distinction in psycho297. pathology. ?. abnorm, soc. Psychol., 1962, 65, FINE, H. L, FULKERSON,S. C., & PHgLLIPS,L. Mal. 215-222.
der conditions of experimental stress (Feffee & Phillips, 1953; Gerard & Phillips, 1953) and achieved level of psychological development (Grace, 1956; Lane, 1955; Smith & Phillips, 1959). Others have reNted competence level to achievement motivation (Broverman, Jordan, & Phillips, 1960), the response to threat (Garmezy & Rodnick, 1959), and to various aspects of cognitive performance (Broverman, 1964). Assessment of program impact requires the consideration of at least two aspects of program performance: its effectiveness and the efficiency with which it is carried out. In order to evaluate effectiveness, explicit program objectives must be spelled out in terms that are subject to measurement. In this light, the competence criterion is superior to the therapeutic criterion, for it is more amenable to direct, objective, and quantitative assessment. Program efficiency may be defined in terms of the cost of a given unit of successful achievement, for example, an increase in earning power measured in terms of additional dollars of income per year. Adoption of the competence criterion as an alternative to any index of change in pathological state encourages the develop. ment of alternate forms of community mental health programs in addition to the present primary commitment to psychothera. peutic and pharmacological procedures. These programs should be free to compete in the market place and to be judged ac. cording to their relative contributions to community mental health, measured in terms of their efficacy and efficiency.
