In the case of depression, a person’s symptoms may include psychomotor slowing that would impact ability to keep pace in a work environment; the impairment produced by the depression, psychomotor slowing, affects the activity of keeping pace in the work environment. If within a specific context the person has access to effective medication in the form of antidepressants, in time the psychomotor slowing could improve. The provision of medication in this context can impact a person’s ability to participate effectively, in this case to keep pace in the work environment. Interventions like medication or reasonable accommodations in a work setting target disparities between a person’s potential (activity) and actual performance (participation) in a given context. Let us turn our focus from the general to a specific scenario.

The following scenario will help illustrate the utility of the biopsychosocial framework of the ICF for case conceptualization and research in mental health management. A similar presentation is included in a recent discussion of the ICF and its contributions to qualitative research in healthcare outcomes [13]. Our scenario involves a 19-year-old female who is gay, who due to a head trauma has a mild neurocognitive disorder and a co-occurring diagnosis of major depressive disorder, recurrent and severe, due to general medical condition (the head trauma). The ICF’s conceptual framework would first encourage us to consider any changes in body structures (head trauma to brain structures and their sequelae, changes in brain neurotransmission that may be associated with depression) and related body functions (impaired neuropsychological functioning, including physical, cognitive, and emotional functioning, depressed mood, and all of its potential consequences). We may measure these changes through clinical interviews, psychological testing, and evaluations by other medical specialties such as neurology, physiatry, counseling, and psychotherapy, with both quantitative data and clinical observation.

During this assessment process, the ICF conceptual framework encourages us to note the differences between functioning potential (activity) and actual functioning within the person’s environmental context (participation). With careful analysis of the person’s context and sensitivity to personal differences (like being a gay woman), the complex relationships between the person’s optimal and actual functioning in her environment can serve as starting points for interventions that will enhance overall functioning and inform research of associated healthcare outcomes.

With respect to contextual factors, if the head injury resulted in mobility impairment, it may be necessary to remove environmental barriers to functioning. If the sequelae of the head trauma or symptoms of depression are difficult for the patient’s coworkers to understand, psychoeducational interventions for coworkers and supervisors may be very useful in creating a supportive environment that maximizes potential for success. Such activities have historically been the domain of job development and support personnel within the vocational rehabilitation system, and the rehabilitation counseling literature has a great deal to offer mental health management professionals in this regard [18].

The interaction between personal and environmental factors may provide targets for intervention. For our example, if the client was not “out” to her family as a gay woman prior to her injury and her family did not know any of her friends from that community and now due to the injury the family is in close contact with her network of friends, there may be a need for healthcare professionals to provide support to the client or, with permission, to family and friends, as relationships evolve in a new social context. This social support system could be critical to achieving optimal rehabilitation outcomes.

Mental health managers or researchers may encounter a variety of perspectives across and within allied healthcare agencies, and understanding differing perspectives of healthcare provision may facilitate future collaborations. If a therapist encounters a healthcare entity focused on the medical model of service provision, the therapist’s advocacy efforts can focus on social and contextual factors to encourage a holistic program of healthcare. A hospital treating the young woman in our example may be focused on medical sequelae of her head trauma, as well as the degree of depressive symptomatology and related risks. The ICF’s conceptual framework addresses these foci through body functions and body structures (which include the brain). In addition, the biopsychosocial approach embraced within the ICF’s conceptual framework will take into careful account contextual issues such as the client’s family system, social circles, and the greater community. Using an interdisciplinary approach across treating sources and with social system support, activities and participation (the client’s potential based upon her functioning and impairments) can be compared with how her current context facilitates or hinders her functioning. In addition, as case conceptualization continues to develop, targeted interventions can proceed in the most comprehensive fashion across treating systems.

The ICF and its conceptual framework can meet a critical need in mental health management, to integrate more detailed information on functional status into health records. The National Committee of Vital and Health Statistics, an academic medical advisory board of the US Department of Health and Human Services, explained the state of the art in 2001, and we have made very modest progress since then:

The point has already been made that administrative data generally do not include information on functional status. The significance of this fact is that information on this dimension of health – increasingly the sine qua non for understanding health – is not available to the healthcare system (e.g., insurers and health plans), nor to the researchers, public health workers, and policy makers who depend on administrative data. What is needed, therefore, is a standardized code set that will enable providers, with minimal burden, to include functional status information in administrative data. [19]

While insurance companies are demanding higher accountability in order to receive payment for services, the information collected is not standard or consistent across entities. Considering our discussion of the ICF conceptual framework as it applies to mental health management, the utility of using the ICF to enhance communication between providers and mental healthcare systems is abundantly clear. See Peterson [10] for a discussion of the international trend to integrate the ICF into national healthcare policies and structures.

A promising development from the American Psychiatric Association in their release of the DSM-5 [17] is the elimination of the Global Assessment of Functioning index, a single number designed to reflect a very complex global construct of overall functioning, and the suggestion to adopt the WHODAS 2.0 in its place, an ICF-based instrument that requires assessment of specific functioning across 36 functional domains. The APA also proposes a variety of crosscutting symptom measures, both within the DSM-5 and many more specific measures that are available on their website, to encourage more careful consideration and documentation of mental health functioning within our healthcare system. The World Health Organization and its ICF appear to have played an important role in this expansion in the consideration of functioning in mental health.

A powerful recovery model paradigm of practice in mental health management, also known as the Boston Model of Psychiatric Rehabilitation, complements the conceptual framework of the ICF and its application to the scenarios just presented. Here is the definition of psychiatric rehabilitation as approved by the United States Psychiatric Rehabilitation Association (USPRA):

Psychiatric rehabilitation promotes recovery, full community integration and improved quality of life for persons who have been diagnosed with any mental health condition that seriously impairs their ability to lead meaningful lives. Psychiatric rehabilitation services are collaborative, person directed and individualized. These services are an essential element of the healthcare and human services spectrum, and must be evidence-based. They focus on helping individuals develop skills and access resources needed to increase their capacity to be successful and satisfied in the living, working, learning, and social environments of their choice. [20]

The recovery model has been advocated within public mental health management [21–23], and its origins lie within psychiatric rehabilitation. The Boston Model of Psychiatric Rehabilitation is a comprehensive model with many elements, not all of which will be reviewed here. One important element of the model is to help the clients manage and live with their mental disorders, rather than expecting or waiting to be symptom-free before returning to full participation in society. The model emphasizes self-determination and input from clients and their family members in the recovery process and in the design and operation of the mental health service system [20].

The psychiatric rehabilitation process as defined by the Boston University Center for Psychiatric Rehabilitation is an evidence-based approach with specific job descriptions, record-keeping formats, and quality assurance mechanism that require intensive training and supervision over time to implement fully [20]. Essential services provided within a recovery-oriented system include treatment for symptom relief, crisis intervention for personal safety, case management for access to services, establishing rehabilitation goals, enrichment activities for self-development, rights protection for equal opportunity, and support for healthy lifestyle, empowerment, and basic support of essential needs. Based on the content of this chapter thus far, there is an obvious confluence of the recovery model and the ICF’s conceptual framework. The individual and contextual foci of both paradigms of practice both promote the utility of a biopsychosocial approach to mental health management.

At the end of the twentieth century, the Surgeon General’s Report on Mental Health [2] suggested that while public understanding of mental illness has improved in recent years, stigma continues to be a major social barrier for people with mental illness. Careful consideration of historical and even recent social discourse, as well as media portrayal of people with psychiatric diagnoses, suggest that the public tends to view people with severe mental illness more negatively than those with physical illnesses [24]. Over the years they have been considered by some to be undesirable as friends, coworkers, tenants, and employees. The mass media often misrepresents and demeans people with psychiatric diagnoses, portraying them as unreliable, erratic, irrational, and violent [25, 26].

In reality, while some people with serious psychiatric diagnoses may be violent, the majority of them are not. There is very little risk of harm to a stranger from casual contact with a person with mental illness, and overall, mental illness has historically made a very small contribution to the total level of violence in society [2]. These stereotypes are humiliating, embarrassing, and painful for people with psychiatric diagnoses [27]. Healthcare management that focuses on actual functioning of people with psychiatric diagnoses could go a long way toward educating the public and disputing long held myths and stereotypes of people dealing with mental illness. The ICF and its conceptual framework, and its etiological neutral approach to disability and function, may help to shift mental health management from the often inaccurate focus on illness onto what is meaningful, actual functioning in an individual’s context [14].

Stigma affects people with mental illness in other ways [26]. It may discourage them from seeking help for their conditions [27]. It may affect their self-esteem and may cause additional stress on those in their social support system. Stigma may have an adverse impact on social relations and may reduce employment and housing opportunities. On the public policy level, stigma has negatively affected the public’s willingness to provide resources for providing mental health treatment and for supporting excellent preparation of mental healthcare service providers.

Using the ICF conceptual framework for intervention targeting, there are things that rehabilitation professionals can do to help reduce stigma [28]. At the contextual level, rehabilitation professionals may address stigma in society by simply bringing psychiatric diagnoses out in the open, allowing people just to talk about it, in order to refute harmful stereotypes and reduce social stigma [27]. They may seek out opportunities to collaborate with other mental health professionals and client advocacy groups (e.g., the National Alliance on Mental Illness) to promote an accurate and sensitive image of people with psychiatric disabilities.

At the workplace environment, rehabilitation professionals may need to help employers and coworkers to dispel the myths surrounding psychiatric diagnoses. Some might fear that people with psychiatric disabilities could become disruptive or violent at work. Others might be concerned that if they accidentally say the “wrong thing,” it will cause the person with a psychiatric disability to become unstable. While these concerns are relevant in some cases, they are overly generalized to encompass all individuals with mental disorders.

Those who have worked long enough in psychiatric rehabilitation realize the value of using counseling skills to help those close to the person with a psychiatric diagnosis to demystify the diagnosis, refute negative stereotypes, offer ideas for reasonable accommodation, and provide an opportunity to change the focus from disability to ability. Rehabilitation professionals providing job follow-up support may need to address ostracism by coworkers or occasional jokes or remarks by insensitive colleagues, whether intentional or unintentional. Finding supportive ways to meet with stakeholders and proactively address such concerns may help avoid the creation of a hostile and stressful work environment.

At the individual level, the client may or may not desire to disclose his or her disability to an employer, depending on the particular job setting, degree of recovery, and personal preferences. Counselors can advise clients about the appropriateness of disclosing or not disclosing psychiatric disability. The decision of whether or not to disclose and how much information to disclose is made on an individual basis and can be informed by good clinical judgment of the rehabilitation counselor. Ultimately, whether there needs to be disclosure depends on a client’s desire to request reasonable accommodation. The consumer and counselor can weigh together the pros and cons of disclosure, so that the consumer can make an informed choice [28].

To conclude this chapter, we will spend some time reviewing the ICF Core Sets developed for depression, the most commonly occurring psychiatric diagnosis in mental health management. ICF Core Sets are specific codes from the ICF related to a specific condition, assembled in order to increase the likelihood of adaption in healthcare settings. The ICF has over 1,400 codes, so developing user-friendly ICF Core Sets focused on specific conditions is a sensible endeavor. Developing an ICF Core Set for depression creates a list of ICF codes related to the most prevalent functional health limitations for depressive disorders.