Hunter Address: Poverty and ''

Can Poverty Drive You Mad? 'Schizophrenia', Socio-Economic Status and the Case for Primary Prevention

John Read, University of Auckland

This paper constitutes the basis of the Address that Dr Read will present at the 2011 NZPsS Conference in association with the Hunter Award.

For several decades the dominance of a rather simplistic, reductionist and women and children. pessimistic ‘medical model’ has, especially in relation to ‘schizophrenia’, – Poverty results in suicide, relegated poverty and its attendant disadvantages (child neglect and abuse, depression, and severe mental overcrowding, dysfunctional families, etc.) to the role of mere triggers of a illness. supposed, but unproven, genetic predisposition. For seventy years, however, research has repeatedly demonstrated not only that poverty is a powerful – Poverty is directly linked to predictor of who develops , and who is diagnosed ‘schizophrenic’ violence. (with or without a family history of psychosis), but that poverty is more . . . . . We believe that the strongly related to ‘schizophrenia’ than to other mental health problems. eradication of poverty is the This paper argues that an evidence-based resolution to the longstanding first step in primary prevention. debate between ‘social causation’ and ‘social drift’ explanations is that the (Albee, 2006, p. 451) former perspective explains how poverty is a major cause of psychosis and the latter explains how poverty is involved in its maintenance. Poverty is After briefly discussing the also a predictor of diagnosis and treatment selection, sometimes regardless relationship between poverty and of actual symptomatology. Evidence is also presented demonstrating mental health in general, this paper that relative poverty may be an even stronger predictor of mental health will (i) examine some of the problems problems, including ‘schizophrenia’, than poverty per se. Psychologists arising from the current dominance of a are encouraged to pay more attention to the psycho-social causes of their rather simplistic bio-genetic paradigm, clients’ difficulties, to the role of the pharmaceutical industry in perpetuating (ii) summarise the extensive research a narrow ‘medical model’ and, most importantly in the long run, to the need demonstrating the causal relationship for primary prevention programmes. between poverty and both psychosis n his 2004 address to the World 1988)...... in general and ‘schizophrenia’ in IConference on the Promotion of – Poverty dampens the human particular, and (iii) delineate some of Mental Health and Prevention of Mental spirit creating despair and the implications at both clinical and and Behavioral Disorders, in Auckland, hopelessness. primary prevention levels. American psychologist George Albee – Poverty underlies multiple The causal role played by poverty in opened with ‘I wrote my first paper problems facing families, infants, a range of mental health problems is well emphasizing the necessity of prevention children, adolescents, adults, and established, including, for example, in of mental disorders nearly 50 years ago’. the elderly. relation to depression (Heflin & Iceland, After demonstrating in some detail the 2009; Talala, Huurre, Aro, Martelin, numerical and economic impossibility – Poverty directly affects infant mortality, mental retardation, & Prattala, 2009), drug abuse (Daniel of trying to provide mental health et al., 2009) and suicidality (Bolton, services to all those who need them, he learning disabilities, and drug and alcohol abuse. Belik, Enns, Cox, & Sareen, 2008). The went on to say: relationship between poverty and poor The principle source of stress – Poverty is a major factor in mental health is, of course, complex worldwide is poverty. Poverty is homelessness. and is mediated by variables that are at the root of many of the stresses – Poverty increases the incidence themselves related to poverty such as that have been identified as the of racial, ethnic, and religious child abuse and neglect, unemployment, cause of emotional distress. hatred. gender, ethnicity, maladaptive coping Poverty has been identified as the – Poverty increases abuse against strategies etc. (Barker-Collo & Read, ‘the cause of the causes’ (Joffe, 2003).

New Zealand Journal of Psychology Vol. 39, No. 2, 2010 • 7 • Dr John Read

Figure 1 poverty and a range of social, health and mental health outcomes than between poverty per se and the same outcomes (Wilkinson & Pickett, 2009). They first note that in many countries rates of mental illness and levels of inequality have both increased significantly in recent decades. They then report a strong relationship between degree of income inequality and rates of people meeting diagnostic criteria for mental illness over a 12 month period, across 11 countries (see Figure 1). Similar findings are reported for other outcomes, including level of use of illegal drugs (Figure 2). In another recent book psychologist and journalist Oliver James coined the term ‘Affluenza’ to describe and explain this phenomenon (James, 2007).

Problems with Construing Madness as an Illness

Dominance of the ‘Medical Model’ The remainder of this paper will focus primarily on the specific relationship between poverty and ‘schizophrenia’, a diagnosis traditionally viewed as one For example, the Christchurch two million New Zealand adults found of the most severe of ‘mental illnesses’ Health and Development study, a that over a three year period the age- and one considered to be particularly prospective birth cohort study adjusted odds ratios for suicide among bio-genetic in origin and the etiology of approximately a thousand New unemployed people, compared to people of which, therefore, is thought to have Zealanders, found that the elevated rates in employment, was 2.46 for women little to do with social factors such as of among Maori involve and 2.63 for men (Blakely, Collings, & poverty. I hope to demonstrate that these an interaction between socioeconomic Atkinson, 2003). Another New Zealand opinions, which are the cornerstones of disadvantage and childhood adversity, study, of over 15,000 families, focussed, the ‘medical model’ of conceptualising with secure cultural identity operating rather unusually, on asset wealth (eg human distress and dysfunction, are not as a protective factor (Marie, Fergusson, home ownership and savings) and found evidence-based. & Boden, 2008). that those in the lowest quintile were The paper will argue that the research three times more likely to report high Furthermore, poverty (like mental summarised above, much of which has psychological distress than those in the health) can, of course, be measured in been undertaken by social scientists, has highest quintile, and that the difference multiple ways, at multiple life stages. had remarkably little impact in the field remained statistically significant even Another longitudinal birth cohort study, of mental health, and discuss possible after controlling for age, gender, prior by the Dunedin Multidisciplinary Health reasons for that. As an illustration of health status, and - perhaps surprisingly and Development Research Unit, found how even the most consistent and robust - income (Carter, Blakely, Collings, that poverty before age 11 (as well as low of research literatures can be ignored, Gunasekara, & Richardson, 2009). IQ at age 5, and antisocial behaviour) minimised or distorted in the service predicted PTSD at ages 26 and 32 It must also be noted that there is of protecting a dominant paradigm (Koenen, Moffitt, Poulton, Martin, & very convincing evidence that relative (Kuhn, 1962), particularly one backed Caspi, 2007). The same study also found poverty is a stronger predictor than by powerful economic interests, we will that while alcohol abuse in adulthood poverty per se. In their book, ‘The Spirit offer some examples of how the research was related to low socioeconomic status Level’ (and on www.equalitytrust.org. demonstrating a strong relationship in childhood, this was not the case for uk), British epidemiologists Richard between poverty and ‘schizophrenia’ depression, which was instead related to Wilkinson and Kate Pickett report (summarised below) has been responded low socioeconomic status in adulthood multiple studies demonstrating a far to within some quarters of the mental (Poulton et al., 2002). A study of over stronger relationship between relative health community.

• 8 • New Zealand Journal of Psychology Vol. 39, No. 2, 2010 Hunter Address: Poverty and 'Schizophrenia'

Figure 2 get their information about the causes of, and treatments for, mental health problems. Recent studies have found that approximately half of all mental health websites are funded by drug companies and that these websites present a more biological perspective about causes and treatments than websites that are free from industry sponsorship, in relation to ‘schizophrenia’ (Read, 2008), PTSD (Mansell & Read, 2009) and depression (de Wattignar & Read, 2009). In 2005 the then President of the American Psychiatric Association warned: If we are seen as mere pill pushers and employees of the pharmaceutical industry, our credibility as a profession is compromised. …. As we address these Big Pharma issues, we must examine the fact that as a profession, we have allowed the bio-psycho-social model to become the bio-bio-bio model (Sharfstein, 2005, p. 3).

The Bio-Psycho-Social Model Even the ‘bio-psycho-social’ model, presented in most sources (including The dominance, for the past several mental health outcomes, the proportion psychology and psychiatry textbooks) decades, of a ‘medical model’ paradigm of studies addressing ‘poverty OR as a balanced, integrated approach to within the mental health field, especially socioeconomic status’ has increased understanding ‘schizophrenia’ and in relation to the more serious ‘illnesses’ since 2000, including ‘major depressive other mental health problems, has been like ‘schizophrenia’, has been repeatedly disorder OR depressive disorder’ (from distorted by the pressure to conform to documented and discussed (Bentall, 0.8% to 1.6%), ‘diabetes’ (0.8% to the dominant paradigm. The landmark 2003, 2009; Boyle, 1990; Read, Mosher, 2.6%) and ‘cardiovascular disease paper introducing the bio-psycho-social & Bentall, 2004a; Ross & Pam, 1995). OR cardiovascular disorder OR heart model, ‘Vulnerability: A new view of For example, a recent review calculated disorder’ (0.8% to 1.5%). schizophrenia’ (Zubin & Spring, 1977), that while 20.6% of all studies of had indeed offered the possibility of a ‘schizophrenia’ ever conducted have The Pharmaceutical Industry genuine integration of psycho-social been concerned with biological causes and biological research. Unfortunately, (and 18.8% with medications) only 0.9% Much of the blame for this imbalance rather than embrace this opportunity, the were concerned with poverty and 0.3% has been focussed on psychiatry’s momentum of the ‘medical model’ was with child abuse or neglect. Furthermore inability or unwillingness to resist the so great that the heightened vulnerability the ratio of studies of biological causes increasingly pervasive influence of to stress, which everyone agreed lay at to studies of social causes has recently the pharmaceutical industry, which the core of psychosis, was decreed to be worsened, from 13.3 to one before 2000 benefits from promulgating a simplistic, biological in origin (usually genetic but to 20.6 to one in the period 2000 to May reductionist focus on biological causal with some attention to perinatal factors). 2009 (Read, Bentall, & Fosse, 2009). factors (Bentall, 2009; Mosher, Gosden, This ignored the fact that Zubin and Despite this disproportionate focus on & Beder, 2004; Shooter, 2005). The Spring had clearly stated that there is the search for biological causes, there industry’s influence on professional such a thing as ‘acquired vulnerability’ have been no robust findings, in terms organisations, research funding, drug and that this can be ‘due to the influence of chemical imbalances or other brain licensing authorities, psychiatric of trauma, specific diseases, perinatal abnormalities (Bentall, 2009; Read, journals and teaching institutions, which complications, family experiences, 2004a) or, as we shall see below, in terms is particularly strong in the U.S.A. adolescent peer interactions, and other of a genetic predisposition. PsycINFO (Mosher, et al., 2004), has recently life events that either enhance or inhibit searches, in February 2010, reveal that, extended to the internet, from which the the development of subsequent disorder’ meanwhile, for many other health and public (and professionals) increasingly

New Zealand Journal of Psychology Vol. 39, No. 2, 2010 • 9 • Dr John Read

(p.109). It is testimony to the power of a of its poor reliability and predictive Since the 1970s the illusion of paradigm, once it establishes dominance, validity, and are focusing instead a balance, of an integration of to resist research findings that refute its on the causes of discrete psychotic models, has been created by the basic premises (Kuhn, 1962) that these phenomena such as hallucinations or so-called ‘bio-psycho-social’ findings are unlikely to prevent the delusions (Bentall, 2009). However, approach. An integral part of this continued consumption of millions of much of the research reported below, has been the ‘vulnerability-stress’ dollars of research funding that might spanning half a century, predates this idea that acknowledges a role for be productively used elsewhere in the recent development and employed the social stressors but only in those mental health field. ‘schizophrenia’ diagnosis. who already have a supposed The failure to find evidence of a genetic predisposition. Life events genetic predisposition for psychosis have been relegated to the role in general, or ‘schizophrenia’ in Summary of the Research of ‘triggers’ of an underlying particular, can be understood in terms genetic time-bomb. This is not of recently developed knowledge Before summarising the research an integration of models, it is a about how epigenetic processes turn demonstrating a causal relationship colonisation of the psychological gene transcription on and off through between poverty and ‘schizophrenia’ and social by the biological. mechanisms that are highly influenced (or psychosis or specific psychotic The colonisation has involved by the individual’s socio-environmental phenomena) it must be noted that, as the ignoring, or vilification, of experiences. To understand the emerging is the case for the other mental health research showing the role of evidence of the relationship between problems briefly discussed at the outset contextual factors such as stress, adverse childhood events, including of this paper, other social factors (many trauma (inside and beyond the poverty, and subsequent psychosis, it is themselves related to poverty) are now family), poverty, racism, sexism necessary to integrate these epigenetic known to have a causal role, or to be etc. in the etiology of madness processes, especially those involving significant risk factors, for psychosis. (Read, Mosher, & Bentall, 2004b, the stress regulating functions of the These include (often after controlling p. 4). HPA axis (Read, Perry, Moskowitz, for family history of ‘schizophrenia’ or & Connolly, 2001), with research psychosis): mother’s health, nutrition about the psychological mechanisms The attempt to prove the hypothesis and stress during pregnancy; urban birth by which specific types of childhood underlying biological psychiatry’s and urban living; being the product of trauma can lead to specific types of distorted version of Zubin and Spring’s an unwanted pregnancy; early loss psychotic experiences (Read, Bentall, model, i.e. that there is a specific genetic of parents via death or abandonment; Fosse, 2009). predisposition for something called separation of parents; witnessing ‘schizophrenia’, has probably been one inter-parental violence; dysfunctional of the most wasteful enterprises ever The ‘Schizophrenia’ Construct parenting (often intergenerational) undertaken by medical researchers. – particularly affectionless over- Recent editorials suggest that these Reviewing the methodologies and control; childhood sexual, physical and ‘inconsistent results and disappointing concepts deployed in the search for a emotional abuse; childhood emotional findings of genetic research on genetic predisposition shows that there or physical neglect; insecure attachment ‘schizophrenia’ arise from ‘failure to is no robust evidence for it (Joseph, in childhood; bullying; war trauma; demonstrate the existence of a unitary 2006). A recent paper in the American rape or physical assaults as an adult; disease process’ (Ruggeri & Tansella, Journal of Psychiatry (Sanders et al., being a refugee; racist and other forms 2009 ) and that ‘the difficulty in gaining 2008), described by the editor as ‘The of discrimination; and heavy marijuana a consistent and clear-cut picture of the most comprehensive genetic association use, especially early in adolescence genetics of schizophrenia mirrors the study of genes previously reported (Bentall & Fernyhough, 2008; Conus, marked clinical and neurobiological to contribute to the susceptibility to Berk, & Schafer, 2009; Janssen et al., heterogeneity of the disorder’(Tosato schizophrenia’ (S. Hamilton, 2008), 2003; Janssen et al., 2004; Larkin & & Lasalvia, 2009) . found that: Morrison, 2006; Larkin & Read, 2008; The construct of ‘schizophrenia’ None of the polymorphisms Mortensen et al., 1999; Moskowitz, is indeed heterogeneous. It is also were associated with the Schafer, & Dorahy, 2008; Parrett & disjunctive, meaning that one person can schizophrenia phenotype at Mason, 2010; Pfeifer et al., 2010; receive the diagnosis without having any a reasonable threshold for Read, Agar, Argyle, & Aderhold, 2003; thing in common with another person statistical significance' and that Read, et al., 2009; Read & Gumley, with the same diagnosis. It also has little 'of the 69 SNPs (single nucleotide 2008; Read, et al., 2001; Read, van Os, reliability or validity (Bentall, 2003, polymorphisms) ... only four Morrison, & Ross, 2005; Schreier et al., 2009; Read, 2004b), rendering it very showed even nominal association. 2009; Shevlin, Dorahy, & Adamson, difficult to identify any specific cause, ... The distribution of test statistics 2007; Shevlin, Murphy, Houston, & genetic or otherwise. Indeed many suggests nothing outside of what Adamson, 2009; Verdoux & Tournier, researchers are abandoning research would be expected by chance (p. 2004). The relationship between into ‘schizophrenia’, precisely because 421). poverty and ‘schizophrenia’, therefore,

• 10 • New Zealand Journal of Psychology Vol. 39, No. 2, 2010 Hunter Address: Poverty and 'Schizophrenia' is best understood as being the result exception, these studies have with the international literature (Abas, of the greater exposure to a range of shown that schizophrenia occurs Vanderpyl, Robinson, & Crampton, risk factors, in both childhood and most frequently at the lowest 2003; Kydd, Nola, & Wright, 1991; adulthood, which are disproportionately social class levels of urban Salmond & Crampton, 2000). experienced by poorer people. society. The evidence comes from A British study found that deprived Mental hospitals and their research in Canada, Denmark, children are four times more likely to precursors have always been filled Finland, Great Britain, Norway, develop ‘non-schizophrenic psychotic predominantly with poor people (Read, Sweden, Taiwan, and the United illness’ but eight times more likely to 2004c). In seventeenth century France, States - an unusually large grow-up to be ‘schizophrenic’ than non- for example, the people confined in the number of countries and cultures deprived children (Harrison, Gunnell, Hopital General were almost exclusively for establishing the generality of Glazebrook, Page, & Kwiecinski, the poor of Paris (Foucault, 1965). In the any relationship in social science. 2001). Even among children with no 19th century (prior to the invention of (Kohn, 1976, p. 177) family history of psychosis the deprived the diagnostic category ‘schizophrenia’ children were seven times more likely to in 1911 (Read, 2004d) reports had Subsequently, a New York study of develop ‘schizophrenia’, confirming that already been emerging that insanity was first admissions found that class V were you do not need a genetic predisposition more common amongst poor people 12 times more likely to be hospitalised to develop ‘schizophrenia’. (Bresnahan & Susser, 2003). than class I. Furthermore: A recent population-based The first systematic study, in 1939, The variable related to the longitudinal study in Israel found that found that the deprived central areas most other variables in this education level of father, education of Chicago had higher psychiatric population and hence important level of mother and occupational status admission rates than the wealthier for understanding many processes of father (all at birth) were significant suburbs (Faris & Dunham, 1939). involved in the functioning of risk factors for being diagnosed with Contrary to the popular notion that these patients is membership ‘schizophrenia’ (Werner, Malaspina, & milder mental health problems, but not in class V. None of the clinical Rabinowitz, 2007). However another ‘schizophrenia’, are socially caused, variables such as a particular analysis of the same data found no the difference was particularly high for symptom dimension or even level gradient of risk for ‘schizophrenia’ 'schizophrenia'. People in the poorest of social functioning relates to as associated with social class at birth, and areas of Chicago were seven times more many other variables. . . . . This that only the offspring of fathers in the likely to be diagnosed 'schizophrenic' is in striking contrast to the low lowest social class had increased risk than those in the richest parts. level of attention often paid to (Corcoran et al., 2009). This relationship between poverty social class in psychiatric practice Researchers measuring the more and 'schizophrenia' was soon replicated and research. (Strauss, Kokes, homogenous and reliable constructs in nine other cities throughout the USA Ritzler, Harder, & VanOrd, 1978, of hallucinations and delusions have (Clark, 1949). During the 1950s the p. 620) found, unsurprisingly, that they are more same relationship was found in Norway, common among people who grew up Bristol, Liverpool and London (Kohn, in poverty (Brown, Susser, Jandorf, & The following year a Tennessee 1976). The famous New Haven study Bromet, 2000). study of 10,000 first admissions again (Hollingshead & Redlich, 1958), which confirmed that the diagnosis most Some researchers have returned measured class directly on the basis of strongly related to low socio-economic to the methodology of the original education and occupation rather than status was ‘schizophrenia' (Rushing Chicago study (Faris & Dunham, 1939) location, found that the poorest class & Ortega, 1979). The relationship and focused on community (rather than (V: 'unskilled, manual') was three times between ‘schizophrenia’ and poverty individual) measures of poverty. For more likely than the wealthiest two was described as ‘one of the most example the Israel data reveals that classes (I and II: 'business, professional consistent findings in the field of being born in a poor neighborhood is and managerial') to be treated for psychiatric epidemiology’ (Eaton, itself a risk factor for ‘schizophrenia’ psychiatric problems. The diagnosis 1980). (Werner, et al., 2007). Similarly a study having the strongest relationship with of 811 counties across 13 states in the More recent research has continued, class was, again, 'schizophrenia'. The USA found that rates of hospitalization with some rare exceptions (see poorest people were eight times more for ‘schizophrenia’ correlated with Bresnahan & Susser 2003), to confirm likely to be diagnosed 'schizophrenic' percentage of residents living in poverty the earlier findings, including studies than the wealthiest. and percentage unemployed (Fortney, in England (Bristol, Nottingham and Xu, & Dong, 2009). A New Zealand London), Wales, Finland, Canada and study found that the relationship By 1976 a review had concluded: Nigeria (Read, 2004e). More often than between poverty and probability of There have been more than not the strongest relationship between being admitted to a 50 studies of the relationship class and psychiatric admission is for exists even within a deprived region. between social class and rates ‘schizophrenia’. New Zealand studies In South Auckland, one of the poorest of schizophrenia. Almost without have produced findings consistent areas of New Zealand, those living in

New Zealand Journal of Psychology Vol. 39, No. 2, 2010 • 11 • Dr John Read the most deprived neighborhoods were, distribution of a composite deprivation ‘social selection’ theory (Eaton, 1980) after controlling for age and gender, score) was associated with incidence suggested that although 'schizophrenics’ 4.1 times more likely to be admitted of ‘schizophrenia’ (after adjusting for have not actually drifted downwards than those living in the least deprived age, sex, absolute deprivation, and themselves, their impoverished neighborhoods. The most common ethnicity), but only in the group of the circumstances are still a result, rather diagnostic category was ‘schizophrenia most deprived wards (Boydell, van Os, than a cause, of their ‘illness’, because and schizoaffective disorder’ (Abas, et McKenzie, & Murray, 2004). A similar they are of a lower social status than al., 2003). An earlier study, of the whole South Africa study, comparing seven their parents, or, weaker still, because Auckland region, had found that the municipalities, found no significant they have not climbed up the pyramid highly significant correlation (p < .0001) relationship between a poverty measure as far as they should have – the ‘social between admission rates and a measure (percentage of residents above or below residue’ theory. of deprivation (including unemployment, the national poverty line) and being Those who argue that the relationship overcrowding, ethnic minority status, treated for a first episode of psychosis. between poverty and ‘schizophrenia’ is and unskilled employment) was largely However the study did find a significant best explained by these theories, rather accounted for by the particularly large relationship with inequality, measured than by a ‘social causation’ model, tend correlation in South Auckland (Kydd, by the mean annual income of the not to mention that the New Haven study et al., 1991). top 10% wage earners divided by the had tested the 'social drift' theory, by Psychiatric admission rates mean annual income of the bottom investigated whether 'class V patients increase during economic declines. 10% (Burns & Esterhuizen, 2008). The had drifted to the slums in the course of This relationship is, again, particularly relationship remained significant after their lives' and whether 'schizophrenics’ strong for psychoses in general and controlling for gender, age, ethnicity, were socially downward mobile. No 'schizophrenia' in particular. (Thompson urbanicity and employment status. evidence of such ‘social drift’ was et al., 2002; Warner, 1985) found. The study also rejected the These repeated findings, that higher weaker social selection theory because levels of disturbance (of the kind found Explanations 91% of the 'schizophrenics' were in in supposedly more biologically-based The figures, presented earlier, about the same social class as their parents illnesses like ‘schizophrenia’) are more the relative dearth of research into - rather than a lower class as predicted related to poverty and other social poverty and the various disadvantages (Hollingshead & Redlich, 1958). In factors than mild or moderate levels of and adverse life events associated with fact an even earlier 25-year study had disturbance, is indirectly supported by poverty, indicate that the most common already failed to find evidence of social the New Zealand study referred to in response from the mental health drift and had concluded that ‘The excess Figure One (Wells et al., 2006). Even community is not to try and explain the of psychoses from the poorer area is a without including the psychosis data powerful relationship between poverty product of the life conditions entailed (which is not reported), this interview and madness at all. The most common in the lower socio economic strata of survey of nearly 13,000 adult New reaction, it seems, is just to ignore it. the society’ (Lapouse, Monk, & Terris, Zealanders found that those with no Another common response has been to 1956). education were 1.2 times more likely deploy the distorted version of Zubin A later Canadian study reported than those with education beyond and Spring’s stress-vulnerability model, measurements of class and psychiatric school to be diagnosed with any DSM arguing that if poverty is involved at all disorder taken ten years apart and diagnosis, but 1.8 times more likely in the etiology of ‘schizophrenia’ then found 'that socio-economic status was to be assessed as having a ‘serious it is only as a trigger or exacerbater of more likely to have causal priority disorder’; with corresponding rates for the ‘illness’ and only in those with the over psychiatric disorder than the the lowest vs highest income groups of supposed genetic predisposition. Other reverse' (Lee, 1976). This longitudinal 1.7 for ‘any disorder’ but 2.9 for ‘serious attempts to explain the relationship approach was repeated in Illinois and disorder’. follow. Michigan, using multiple points in time. In both states the results 'favour a social causation interpretation' (Wheaton, Relative poverty Can madness cause poverty? 1978). Although psychosis was not included One explanation, which protects the Beyond predicting who becomes in the studies summarized in Figure dominance of the bio-genetic paradigm, ‘schizophrenic’ in the first place, low One, the authors of The Spirit Level is to argue that 'schizophrenia' afflicts ‘social class of origin’ (at birth or during point out that ‘severe mental illness’ all classes equally but those at the top childhood), which ‘cannot be caused by is ‘strongly correlated with inequality; of the economic pyramid dribble down schizophrenia’, also predicts negative mood disorders less so’ (Wilkinson & to the bottom as result of their ‘illness’. outcome among people with severe Pickett, 2009). There is good evidence to This is the ‘social drift’ theory. Because psychosis (Samele et al., 2001). support the relative poverty hypothesis of the paucity of evidence supporting The relationship between urbanicity in relation to psychosis. A study of the ‘social drift’ notion (Read, 2004e), and ‘schizophrenia’ has been shown to 17 wards in South London found that psychiatry has fallen back on weaker be less a consequence of social drift or high inequality (measured by degree of variations of the same theme. The social residue (Dauncey, Giggs, Baker,

• 12 • New Zealand Journal of Psychology Vol. 39, No. 2, 2010 Hunter Address: Poverty and 'Schizophrenia'

& Harrison, 1993) than a consequence From this it is concluded that the behavior’ rather than ‘occupation and of growing up in the city (Marcelis, 'relationship of class to schizophrenia education’. Thus there was ‘intellectual Navarro-Mateu, Murray, Selten, & Van is not attributable to the amount of denial of social status effects and Os, 1998). stress that people endure. There must a subconscious utilization of status Of course there are social and also be important class differences information’ (Lebedun & Collins, 1976, economic consequences to being in how effectively people deal with p. 206). British clinical psychologist extremely distressed, alienated or stress.' In particular the poor have Lucy Johnstone concluded: disoriented. There are additional inadequate 'conceptions of social A number of studies have found consequences, such as stigma – both reality' characterised by ‘fearfulness that severer diagnoses are given from without and internalised - which is and distress, and by a fatalistic belief to working- than to middle-class exacerbated by having one’s difficulties that he is at the mercy of forces beyond patients, regardless of symptoms; explained in terms of having a ‘mental his control and often beyond his that the former are seen as having illness’ (Angermeyer & Matschinger, understanding’ (Kohn, 1976, p. 179). a poorer prognosis; and that 2005; Read, 2007; Read, Haslam, Paranoia, it seems, is sometimes a rofessionals are less interested in Sayce, & Davies, 2006). In addition, heightened state of awareness. If poor treating them. (Johnstone, 2000, anti-psychotic medications, along people do have limited ways to deal p. 238) with any beneficial effects, have a with stress, this is, to a large extent, just range of adverse effects which can another consequence of being poor. severely limit one’s social, cognitive, In a rather extreme example of Public Opinion and occupational functioning ((Bentall, the power of dominant paradigms to The idea that poverty, and all 2009; Ross & Read, 2004; Weinmann & influence its adherents to act in ways that its attendant adversities, can cause Aderhold, 2010; Weinmann, Read, & protect the paradigm from incongruent ‘schizophrenia’, while still contentious Aderhold, 2009). Therefore it would be realities, it was seriously proposed that for some mental health experts, is surprising if the social drift hypothesis no further research be undertaken on not controversial to the public. In 16 had no empirical support. A reasonable the topic, and that researchers should countries where surveys about the conclusion to draw is that both social 'look for class-constant stresses, not causes of ‘schizophrenia’ have been causation and social drift are at play stressors that are more frequent in the conducted, the public (including patients here, the former in the causation of lower class, such as events related to the and their family members) place more ‘schizophrenia’ and the latter in its economy' (Eaton 1980). It seems this emphasis on psycho-social causes than maintenance. blatantly ideological recommendation bio-genetic factors (Angermeyer & has not gone entirely unheeded. Other Matschinger, 2005; Magliano et al., reviewers concur with our earlier 2009; Read, et al., 2006). For example, Poor people don’t face more comments in concluding that ‘Societal the most endorsed causal model of stress, they just can’t deal with it influences have rarely been addressed ‘schizophrenia’ amongst Londoners was Some psychiatrists have argued that in recent reviews of schizophrenia’ ‘Unusual or traumatic experiences or the it is not the disadvantages accompanying (Bresnahan & Susser 2003, p. 8). These failure to negotiate some critical stage poverty that are responsible, and have particular reviewers, however, argue of emotional development’, followed claimed instead that poor people are that ‘socioeconomic status has at most by ‘Social, economic, and family oversensitive to stress and therefore a modest effect on risk of schizophrenia’ pressures.’ (Furnham & Bower, 1992). can’t deal with it. Some have even and that ‘no clear findings have emerged’ In a survey of over 2.000 Australians argued that poverty doesn’t involve (p.5). Other reviewers concur with the the most frequently cited cause (94%) exposure to disproportionate amounts current author’s reading of the research, was ‘Day-to-day-problems such as of stressors. For example, researchers i.e. that both social causation and social stress, family arguments, difficulties at who found ten-fold differences in selection processes are clearly operating work or financial difficulties’ (Jorm et ‘schizophrenia’ between the poorest (Mohler & Earls, 2002). al., 1997). and wealthiest parts of Nottingham saw 'no clues' about causes: ‘There was Campaigns (often funded by drug no particular suggestion of unusually Biased diagnoses companies) to persuade the public to drop high rates of stressful events' (Giggs There is another reason, besides their belief that bad things happening & Cooper, 1987, p. 633). Others have social causation, why poor people can drive you mad and accept instead claimed ‘there is little evidence that have a higher chance of ending up that ‘schizophrenia’ is a biologically lower-status individuals suffer from diagnosed 'schizophrenic'. By 1977 based ‘illness’, have been shown to more situationally induced stress’ there were nine studies showing that increase fear and prejudice rather than, (Rushing & Ortega, 1979, p. 1192). more severe diagnoses are applied to as claimed, reduce it (Dietrich et al., 2004; Read, 2007). It has even been argued that 'at any poorer people than wealthier people given level of stress, people of lower with the same symptoms (Abramowitz & social class position are more likely Dokecki, 1977). A tenth study found that to become mentally disturbed than are psychiatrists assigning severe diagnoses Treatment people of higher social class position’. on the basis of class genuinely believed Class bias operates not only in the they were basing diagnoses on ‘patient’

New Zealand Journal of Psychology Vol. 39, No. 2, 2010 • 13 • Dr John Read diagnostic process but in treatment Poverty is also a powerful predictor research and clinical practice. Indeed selection as well. Hollingshead of compulsory admissions (Bindman, largely abandoned and Redlich (1958) had found that Tighe, Thornicroft, & Leese, 2002). the whole field of psychosis for forty years 57% of class V (unskilled, manual) For example., a study of the Auckland after the introduction, in the 1950s, of 'schizophrenics', but 24% of class region of New Zealand found that the first anti-psychotic drugs, preferring I and II (business, professional and compulsory admissions were highly to focus on areas like depression and managerial) 'schizophrenics', received correlated with neighbourhood levels anxiety. Some of the leading cognitive nothing more than 'custodial care'. Class of deprivation (p < .0001), and – again psychologists, mostly British, who broke V patients were more likely to receive – that the strongest correlation was in psychology’s silence about madness in physical treatments such as E.C.T, drugs the most deprived area, South Auckland the 1990s, have paid proper attention to and lobotomy. In the same population, (Kydd, et al., 1991). trauma (Bentall, 2003, 2009; Larkin & ten years later, the poor were more likely Morrison, 2006). Many psychologists, to be hospitalised, were kept in hospital however, either continue to stay well longer and received fewer treatments Therapeutic and Policy clear of hallucinations and delusions associated with discharge (Myers & Implications or conceptualise such experiences as Bean, 1968). A 1977 review confirmed evidence of individual psychopathology that working class people were more rather than as understandable reactions likely to be treated with drugs than In an earlier review of the literature, to adverse life events. For example, with psychotherapy (Abramowitz & the current author put forward the there is an absence or paucity of family Dokecki, 1977). More recently, it has argument that: therapists in many mental health services been concluded that: There appears to be a circle of throughout the world. In the psychosis Working class patients are, like oppression operating, in which field this may be partly explained by black and ethnic minority patients, biological psychiatry plays a psychologists’ fear of being accused more likely to be prescribed crucial role. Of course the poor in of ‘family blaming’, a derogatory term physical treatments such as any society are subjected to more frequently deployed by biological drugs and ECT, to spend longer sources of stress than the wealthy. psychiatry and the drug industry for periods in hospital regardless of In many societies poverty extends researchers and clinicians who adopt diagnosis, and to be readmitted, to hunger and homelessness. Even a family systems paradigm (Read and, correspondingly less likely those with enough to eat and & Bentall, in press; Read, Seymour, to be referred for the more somewhere to live are more likely & Mosher, 2004). The continuing ‘attractive’ treatments such as to experience powerlessness, adherence of some psychologists to psychotherapy or group therapy. isolation, lack of self-respect, the idea that a diagnosis somehow (Johnstone, 2000, p.238) physical ill-health etc...... explains the causes of a problem Having entered the system they (e.g. the hallucinations are caused by are more likely, regardless of their the schizophrenia) may inhibit them For example, a recent survey of behaviour, to be hospitalised and from looking further or deeper for an nearly 900,000 American children and labelled 'schizophrenic'. This explanation. adolescents showed that youths whose is likely to further lower their All mental health professionals will, families are eligible for Medicaid (i.e. self-esteem and motivation, and if they ask the right questions (Read, from poor families) are 5.8 times more to frighten and distance loved Hammersley, & Rudegeair, 2007), and likely to be on anti-psychotic drugs than ones. . . . . They are less likely are not seduced by the delusion that those from families with private health to be able to understand the real counting symptoms and applying labels insurance and, therefore, access to a origins of their distress since helps you understand what is going on broader range of treatments (Zito et al., this has all been explained away for the person in front of you, repeatedly 2003). A study of short-term inpatients by their being 'schizophrenic'. hear of the social causes of their clients’ in Alabama found that while race They will, as a result, be even difficulties. Most of those social causes and gender did not predict discharge more powerless to change the are related to poverty. Of course there placement, more patients of lower circumstances that caused them to are restraints on what an individual socioeconomic class were transferred enter the psychiatric system in the professional can do to help alleviate the into long-term hospitalization (L. first place. (Read, 2004e, p. 168) poverty of an individual client or family, Hamilton, 2007). Adults from the more especially when the prevailing paradigm deprived areas of South Auckland, says its irrelevant and your agency tells New Zealand (after adjusting for It would, of course, be simplistic you ‘its not your job.’ other demographic factors, diagnosis, to lay all the blame at the door of chronicity, severity, psychiatrist and biologically-oriented psychiatrists We could, however, try a little involuntary admission) had longer stays and the pharmaceutical industry that harder. The chief of Public Psychiatry at in psychiatric hospital than those from bankrolls their narrow paradigm. the University of Chicago (19, p.1046) less deprived areas (Abas, Vanderpyl, Some psychologists, including clinical reminds us, that ‘the seriously mentally Robinson, Le Proux, & Crampton, psychologists, adopt an equally ill are poor’ and that: 2006). individualised, contextless approach to

• 14 • New Zealand Journal of Psychology Vol. 39, No. 2, 2010 Hunter Address: Poverty and 'Schizophrenia'

With poverty and unemployment the field of psychosis currently tends to social and mental health outcomes, come all the other social mean identifying troubled teenagers who will work also to reduce the prevalence consequences of being underclass meet criteria for the recently invented of madness. Persuading government – vagrancy, panhandling, notion of ‘prodromal’ psychosis and to invest in the first five years of life substance abuse, and crime. treating them as soon as possible, will be just as important in relation to Yet, with appropriate resources predominantly with anti-psychotic reducing psychosis as it is for other for supported housing and job medication (Bentall & Morrison, 2002; adverse outcomes. For example, an placement, the panhandling, Boyle, 2004). The huge recent increases environmental enrichment programme at dishevelled, homeless mentally ill in the prescribing of these drugs to age 3-5 years has been shown to reduce person can become just another adolescents that have resulted (Ross & schizotypal traits in early adulthood neighbour. (Luchins, 2004) Read, 2004) seem set to soar further if (Raine, Mellingen, Liu, Venables, & the proposal to introduce a new diagnosis Mednick, 2003). called ‘psychosis-risk syndrome’ in the We could certainly act on the The case for primary prevention, DSM-V is implemented (Morrison, growing body of research showing and for a special focus on the first Byrne, & Bentall, 2010; Ross, 2010). that psychological therapies, especially five years of life, has been repeatedly Other commentators, however, argue those with a greater focus on the made, for years, all over the world, in that ‘this is the right direction to move therapeutic relationship and on the relation to a broad array of outcomes. in if we want to regain the space for a client’s understanding of the origin and The only thing new, therefore, in this more psychosocial-based psychiatry’ meaning of their difficulties (Bentall, paper, is the research showing that, (Johanessen & McGorry, 2010) 2009; Geekie & Read, 2009) are at psychosis, ‘schizophrenia’ madness or least as effective as anti-psychotic If we were to take an evidence- whatever you prefer to call it, is, like drugs (Alanen, de Chavez, Silver, & based approach to the question of ‘what most other mental health problems, Martindale, 2009; Bola, Lehtinen, should be done about schizophrenia?’ largely caused by those social factors Cullberg, & Ciompi, 2009; Morrison, we would be likely to conclude that the that are particularly common amongst 2009; Randal et al., 2009, 2010; Read, same primary prevention programmes the poor. Mosher, et al., 2004a) and do not cause to reduce child poverty, child abuse The researchers in the Dunedin neurodegeneration, sexual dysfunction, and neglect, and so on, that seem to Multidisciplinary Health and obesity and diabetes, and do not increase have some effect on other health, Development Research Unit, cited cardiovascular risk or reduce life span (Bentall, 2009; Bentall & Morrison, Figure 3 2002; Ross & Read, 2004; Weinmann & Aderhold, 2010; Weinmann, et al., 2009). We could also use what the research and our clients tell us to try a little harder to lobby government to act in ways to reduce absolute and relative poverty, so as to help prevent ‘schizophrenia’ and other mental health problems in the next generation. It is has been repeatedly argued that our efforts in this regard, and in establishing primary prevention programmes aimed at reducing poverty, should be targeted at the early years of life (Davies, Hanna, & Crothers, 2010; Perry, 1999). The brain differences between ‘normal’ and ‘schizophrenic’ adults, for decades cited as evidence that ’schizophrenia’ is a brain disease which has little to do with childhood events, are found in the brains of children traumatised in the first few years of life (Braehler et al., 2005; Read, et al., 2001). A common response to findings of high admission rates from deprived neighbourhoods, is to call for more inpatient beds in those areas (Abas, et al., 2003). Meanwhile ‘prevention’ in

New Zealand Journal of Psychology Vol. 39, No. 2, 2010 • 15 • Dr John Read earlier, concluded: References mental illness. Journal of Mental Health, 11, 351-356. Bindman, J., Tighe, J., Thornicroft, G., Protecting children against the Abas, M., Vanderpyl, J., Robinson, E., & & Leese, M. (2002). Poverty, poor Crampton, P. (2003). More deprived areas effects of socioeconomic adversity services, and compulsory psychiatric need greater resources for mental health. could reduce the burden of disease admission in England. Social Psychiatry Austalian and New Zealand Journal of experienced by adults. These and Psychiatric Epidemiology, 37(7), Psychiatry, 37, 437-444. findings provide strong impetus 341-345. doi: http://dx.doi.org/10.1007/ for policy makers, practitioners, Abas, M., Vanderpyl, J., Robinson, E., Le s00127-002-0558-3 Proux, T., & Crampton, P. (2006). Socio- and researchers to direct energy Blakely, T., Collings, S., & Atkinson, J. economic deprivation and duration of (2003). Unemployment and suicide. and resources towards childhood hospital stay in severe mental disorder. Evidence for a causal association? as a way of improving population British Journal of Psychiatry, 188(6), Journal of Epidemiology & Community health. (Poulton, et al., 2002, p. 581-582. doi: http://dx.doi.org/10.1192/ Health, 57(8), 594-600. doi: http://dx.doi. 164) bjp.bp.104.007476 org/10.1136/jech.57.8.594 Abramowitz, C., & Dokecki, P. (1977). Bola, J., Lehtinen, K., Cullberg, J., & Ciompi, The politics of clinical judgment: Early The focus on relative poverty should L. (2009). Psychosocial treatment, empirical returns. Psychological Bulletin, antipsychotic postponement, and low not be forgotten when planning primary 84(3), 460-476. doi: http://dx.doi. dose medication strategies in first episode prevention programmes. Figure 3 shows org/10.1037/0033-2909.84.3.460 the relationship between inequality and psychosis: A review of the literature. Alanen, J., de Chavez, M., Silver, A., the ‘Index of child wellbeing in rich Psychosis: Psycholgical, Social and & Martindale, B. (Eds.). (2009). Integrative Approaches, 1(1), 4-18. countries’, a measure combining 40 Psychotherapeutic approaches to Bolton, J. M., Belik, S.-L., Enns, M. W., indicators complied by UNICEF. The schizophrenic psychoses: Past present Cox, B. J., & Sareen, J. (2008). Exploring authors of ‘The Spirit Level’ conclude: and future. London: Routledge. the correlates of suicide attempts among Albee, G. (1996). Revolutions and counter- individuals with major depressive The solution to problems revolutions in prevention. American disorder: Findings from the National Psychologist, 51, 1130-1133. caused by inequality is not mass Epidemiologic Survey on Alcohol and psychotherapy aimed at making Albee, G. (2006). Historical Overview of Related Conditions. Journal of Clinical Primary Prevention of Psychopathology: everyone less vulnerable. The best Psychiatry, 69(7), 1139-1149. Address to The 3rd World Conference Boydell, J., van Os, J., McKenzie, K., & way of responding to the harm on the Promotion of Mental Health and done by high levels of inequality Murray, R. (2004). The association Prevention of Mental and Behavioral of inequality with the incidence of would be to reduce the inequality Disorders September 15-17,2004, schizophrenia: An ecological study. itself. Rather then requiring Auckland, New Zealand. The Journal Social Psychiatry and Psychiatric anti-anxiety drugs in the water of Primary Prevention, 27(5), 449-456. Epidemiology, 39(8), 597-599. doi: http:// supply or mass psychotherapy, doi: http://dx.doi.org/10.1007/s10935- dx.doi.org/10.1007/s00127-004-0789-6 006-0047-7 what is most exciting about the Boyle, M. (1990). Schizophrenia: A scientific picture we present is that it shows Angermeyer, M., & Matschinger, H. (2005). delusion. London: Routledge. Causal beliefs and attitudes to people that reducing inequality would Boyle, M. (2004). Preventing a non-existent with schizophrenia: trend analysis based increase the wellbeing and quality illness? Some issues in the prevention on data from two population surveys in of life for all of us (Wilkinson & of 'schizophrenia'. Journal of Primary Germany. British Journal of Psychiatry, Prevention, 24(4), 445-468. Pickett, 2009, p. 33) 186, 331-334. Braehler, C., Holowka, D., Brunet, A., Barker-Collo, S., & Read, J. (2003). Models Beaulieu, S., Baptista, T., Debruille, George Albee put it this way: of response to childhood sexual abuse: J. B., et al. (2005). Diurnal cortisol in Their implications for treatment. Trauma, schizophrenia patients with childhood Violence, & Abuse, 4(2), 95-111. doi: http:// trauma. Schizophrenia Research, 79(2- Psychologists must join with dx.doi.org/10.1177/1524838002250760 3), 353-354. persons who reject racism, Bentall, R. (2003). Madness explained: Bresnahan, M., & Susser, E. (2003). sexism, colonialism, and Psychosis and human nature. London: Investigating socioenvironmneal exploitation and must find ways to Penguin. redistribute social power and to infuences in schizophrneia: conceptual Bentall, R. (2009). : and design issues. In R. Murray, P. Jones, increase social justice. Primary Why psychiatric treatments fail. London: E. Susser, J. vanOs & M. Cannon (Eds.), prevention research inevitably Penguin. The Epidemiology of Schizophrenia (pp. will make clear the relationship Bentall, R., & Fernyhough, C. (2008). Social 5-17). Cambridge: Cambridge University between social pathology and predictors of psychotic experiences: Press. psychopathology and then will Specificity and psychological Brown, A. S., Susser, E. S., Jandorf, L., work to change social and mechanisms. Schizophrenia Bulletin, & Bromet, E. J. (2000). Social class political structures in the interests 34(6), 1012-1020. doi: http://dx.doi. of origin and cardinal symptoms of of social justice. It is as simple org/10.1093/schbul/sbn103 schizophrenic disorders over the early and as difficult as that! (Albee, Bentall, R., & Morrison, A. (2002). More illness course. Social Psychiatry & 1996, p. 1131) harm than good: The case against using Psychiatric Epidemiology, 35(2), 53-60. anti-psychotic drugs to prevent severe

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Burns, J. K., & Esterhuizen, T. (2008). study of schizophrenia and other Prevention, powerlessness and politics: Poverty, inequality and the treated psychoses. 270. Readings on social change. Newbury incidence of first-episode psychosis: Fortney, J. C., Xu, S., & Dong, F. Park, CA: Sage. An ecological study from South Africa. (2009). Community-level correlates Johanessen, J., & McGorry, P. (2010). DSM- Social Psychiatry and Psychiatric of hospitalizations for persons with 5 and the 'Psychosis Risk Syndrome': Epidemiology, 43(4), 331-335. doi: http:// schizophrenia. Psychiatric Services, The need for a broader perspective. dx.doi.org/10.1007/s00127-008-0308-2 60(6), 772-778. doi: http://dx.doi. Psychosis: Psychological, Social and Carter, K., Blakely, T., Collings, S., org/10.1176/appi.ps.60.6.772 Integrative Approaches, 2(2), 93-96. Gunasekara, F., & Richardson, K. Foucault, M. (1965). Madness and Johnstone, L. (2000). Users and abusers of (2009). What is the association between civilization. New York: Random House. psychiatry. London: Routledge. wealth and mental health? Journal of Furnham, A., & Bower, P. (1992). A Jorm, A. F., Korten, A. E., Rodgers, B., Epidemiology and Community Health, comparison of academic and lay theories Pollitt, P., Jacomb, P. A., Christensen, 63(3), 221-226. doi: http://dx.doi. of schizophrenia. British Journal of H., et al. (1997). Belief systems of the org/10.1136/jech.2008.079483 Psychiatry, 161, 201-210. general public concerning the appropriate Clark, R. (1949). Psychosis, income and Geekie, J., & Read, J. (2009). Making sense treatments for mental disorders. Social occupational prestige. American Journal of madness: Contesting the meaning of Psychiatry and Psychiatric Epidemiology, of Sociology, 54, 433-440. schizophrenia. New York, NY: Routledge/ 32(8), 468-473. Conus, P., Berk, M., & Schafer, I. (2009). Taylor & Francis Group; US. Joseph, J. (2006). The missing gene: Trauma and psychosis: Some aspects Giggs, J., & Cooper, J. (1987). Ecological psychiatry, heredity, and the fruitless of a complex relationship. Acta structure and the distribution of search for genes. New York: Algora. Neuropsychiatrica, 21(3), 148-150. schizophrenia and affective psychoses Koenen, K. C., Moffitt, T. E., Poulton, R., doi: http://dx.doi.org/10.1111/j.1601- in Nottingham. British Journal of Martin, J., & Caspi, A. (2007). Early 5215.2009.00337.x Psychiatry, 151, 627-633. childhood factors associated with the Corcoran, C., Perrin, M., Harlap, S., Deutsch, Hamilton, L. (2007). Disparities in long-term development of post-traumatic stress L., Fennig, S., Manor, O., et al. (2009). state hospitalization for schizophrenia: disorder: Results from a longitudinal birth Effect of socioeconomic status and parents' Race, gender, and socioeconomic class as cohort. Psychological Medicine, 37(2), education at birth on risk of schizophrenia predictors in Alabama. Fielding Graduate 181-192. doi: http://dx.doi.org/10.1017/ in offspring. Social Psychiatry and University. S0033291706009019 Psychiatric Epidemiology, 44(4), 265- Kohn, M. (1976). The interaction of social 271. doi: http://dx.doi.org/10.1007/ Hamilton, S. (2008). Schizophrenia candidate class and other factors in the etiology s00127-008-0439-5 genes: are we really coming up blank? . American Journal of Psychiatry 165, of schizophreia. American Journal of Daniel, J. Z., Hickman, M., Macleod, J., 420-423. Psychiatry, 133, 177-180. Wiles, N., Lingford-Hughes, A., Farrell, Kuhn, T. (1962). The structure of scientific M., et al. (2009). Is socioeconomic status Harrison, G., Gunnell, D., Glazebrook, revolutions. Chicago: University of in early life associated with drug use? A C., Page, K., & Kwiecinski, R. (2001). Chicago Press. systematic review of the evidence. Drug Association between schizophrenia and and Alcohol Review, 28(2), 142-153. social inequality at birth: case-control Kydd, R., Nola, P., & Wright, J. (1991). study. British Journal of Psychiatry, 179, Mental health needs in Auckland 1982- Dauncey, K., Giggs, J., Baker, K., & 346-350. 6: An analysis using the Jarman index. Harrison, G. (1993). Schizophrenia in New Zealand Medical Journal, 104, Nottingham: lifelong residential mobility Heflin, C. M., & Iceland, J. (2009). Poverty, 255-257. of a cohort. British Journal of Psychiatry, material hardship, and depression. Social 163, 613-619. Science Quarterly, 90(5), 1051-1071. Lapouse, R., Monk, M., & Terris, M. (1956). doi: http://dx.doi.org/10.1111/j.1540- The drift hypothesis and socioeconomic Davies, E., Hanna, K., & Crothers, C. 6237.2009.00645.x differentials in schizophrenia. American (2010). Preventing child poverty: Barriers Journal of Public Health, 46, 978-986. and solutions. New Zealand Journal of Hollingshead, A., & Redlich, F. (1958). Psychology, 39, 20-31 Social class and mental illness. New Larkin, W., & Morrison, A. P. (Eds.). (2006). York: Wiley. Trauma and psychosis: new directions for de Wattignar, S., & Read, J. (2009). The theory and therapy. London: Routledge. pharmaceutical industry and the internet: James, O. (2007). Affluenza. London: Are drug company funded depression Vermillion. Larkin, W., & Read, J. (2008). Childhood websites biased? Journal of Mental Janssen, I., Hanssen, M., Bak, M., Bijl, R., De trauma and psychosis: Evidence, Health, 18, 1-10. Graaf, R., Vollebergh, W., et al. (2003). pathways, and implications. Journal of Postgraduate Medicine, 54, 284-290. Dietrich, S., Beck, M., Bujantugs, B., Discrimination and delusional ideation. Kenzine, D., Matschinger, H., & British Journal of Psychiatry, 182(1), Lebedun, M., & Collins, J. (1976). Effects Angermeyer, M. (2004). The relationship 71-76. doi: http://dx.doi.org/10.1192/ of status indicators on psychiatrists' between public causal beliefs and social bjp.182.1.71 judgements of psychiatric impairment. distance toward mentally ill people. Janssen, I., Krabbendam, L., Bak, M., Social Science Research, 60, 199-210. Australian and New Zealand Journal of Hanssen, M., Vollebergh, W., de Graaf, Lee, R. (1976). The causal priority between Psychiatry, 38, 348-354. R., et al. (2004). Childhood abuse as a risk socio-economic status and psychiatric Eaton, W. (1980). A formal theory of factor for psychotic experiences. Acta disorder. International Journal of Social selection for schizophrenia. American Psychiatrica Scandinavica, 109(1), 38- Psychiatry, 22, 1-8. Journal of Sociology, 86, 149-158. 45. doi: http://dx.doi.org/10.1046/j.0001- Luchins, D. (2004). At issue: will the term 690X.2003.00217.x Faris, R., & Dunham, H. (1939). Mental brain disease reduce stigma and promote disorders in urban areas: an ecological Joffe, J. (1988). The cause of the causes. In parity for mental illnesses? Schizophrenia G. Albee, J. Joffe & L. Dusenbury (Eds.), Bulletin, 30(4), 1043-1048.

New Zealand Journal of Psychology Vol. 39, No. 2, 2010 • 17 • Dr John Read

Magliano, L., Fiorillo, A., del Vecchio, H., Parrett, N., & Mason, O. (2010). Refugees gender. In J. Read, L. Mosher & R. Malangone, C., de Rosa, C., Bachelet, and psychosis: A review of the literature. Bentall (Eds.), Models of madness: C., et al. (2009). What people with Psychosis: Psychological, Social and Psychological, social and biological schizophrenia think about the causes of Integrative Approaches, 2(2), 111-121. approaches to schizophrenia (pp. 161- their disorder. Epidemiologia e Psichiatria Perry, B. (1999). Memories of fear. In J. 194). London: Routledge. Sociale, 18, 1, 2009, 18(1), 48-53. Goodwin & R. Attias (Eds.), Splintered Read, J. (2007). Why promoting biological Mansell, P., & Read, J. (2009). Posttraumatic Reflections. Washington: Basic Books. ideology increases prejudice against stress disorder, drug companies, and Pfeifer, S., Krabbendam, L., Myin-Germeys, people labelled "schizophrenic". the internet. Journal of Trauma & I., Derom, C., Wichers, M., Jacobs, L., Australian Psychologist, 42(2), Dissociation, 10(1), 9-23. doi: http://dx.doi. et al. (2010). A cognitive intermediate 118-128. doi: http://dx.doi. org/10.1080/15299730802488494 phenotype study confirming possible org/10.1080/00050060701280607 Marcelis, M., Navarro-Mateu, F., Murray, gene-early adversity interaction in Read, J. (2008). Schizophrenia, drug R., Selten, J. P., & Van Os, J. (1998). psychosis outcome: A general population companies and the internet. Social Urbanization and psychosis: a study twin study. Psychosis: Psycholgical, Science & Medicine, 66(1), 99-109. of 1942-1978 birth cohorts in The Social and Integrative Approaches, doi: http://dx.doi.org/10.1016/j. Netherlands. Psychological Medicine, 2(1), 1-11. socscimed.2007.07.027 28(4), 871-879. Poulton, R., Caspi, A., Milne, B. J., Read, J., Agar, K., Argyle, N., & Aderhold, Marie, D., Fergusson, D. M., & Boden, J. Thomson, W., Taylor, A., Sears, M. V. (2003). Sexual and physical abuse M. (2008). Ethnic identification, social R., et al. (2002). Association between during childhood and adulthood as disadvantage, and mental health in children's experience of socioeconomic predictors of hallucinations, delusions adolescence/young adulthood: Results of disadvantage and adult health: A life- and thought disorder. Psychology and a 25 year longitudinal study. Australian course study. The Lancet, 360(9346), Psychotherapy: Theory, Research and and New Zealand Journal of Psychiatry, 1640-1645. doi: http://dx.doi.org/10.1016/ Practice, 76(1), 1-22. doi: http://dx.doi. 42(4), 293-300. doi: http://dx.doi. S0140-6736%2802%2911602-3 org/10.1348/14760830260569210 org/10.1080/00048670701787545 Raine, A., Mellingen, K., Liu, J., Venables, Read, J., & Bentall, R. (2010). Schizophrenia Mohler, B., & Earls, F. (2002). Social P., & Mednick, S. (2003). Effects of and childhood adversity. American selection and social causation as environmental enrichment at ages 3-5 Journal of Psychiatry. 167(6), 717-718. determinants of psychiatric disorders. In years on schizotypal personality and Read, J., Bentall, R., & Fosse, R. (2009). E. Waring & D. Weisburd (Eds.), Crime antisocial behavior at ages 17 and 23 Time to abandon the bio-bio-bio model and social organisation (pp. 107-118). years. American Journal of Psychiatry, of psychosis: Exploring the epigenetic New Brunswick: Transaction Books. 160, 1627-1635. and psycholgocial mechanisms by which Morrison, A. (2009). Cognitive behaviour Randal, P., Stewart, M., Proverbs, D., adverse life events lead to psychotic therapy for first episode psychosis: Good Lampshire, D., Symes, J., & Hamer, symptoms. Epidemiologia e Psichiatria for nothing or fit for purpose?Psychosis: H. (2010). "The Re-covery Model" Sociale, 18(4), 299-317. Psycholgical, Social and Integrative - An integrated developmental stress- Read, J., & Gumley, A. (2008). Can Approaches, 1(2), 103-112. vulnerability-strengths approach to attachment theory help explain the Morrison, A., Byrne, R., & Bentall, R. mental health. Psychosis: Psychological, relationship between childhood adversity (2010). DSM-V and the Psychosis Risk Social and Integrative Approaches, 1(2), and psychosis? Attachment, 2, 1-35. 122-133. Syndrome: The Risks of Inclusion. Read, J., Hammersley, P., & Rudegeair, T. Psychosis: Psycholgical, Social and Read, J. (2004a). Biolgocial psychiatry's (2007). Why, when and how to ask about Integrative Approaches, in press. lost cause. In J. Read, L. Mosher & child abuse. Advances in Psychiatric Mortensen, P. B., Pedersen, C. B., R. Bentall (Eds.), Models of madness: Treatment, 13, 101-110. Psychological, social and biological Westergaard, T., Wohlfahrt, J., Ewald, Read, J., Haslam, N., Sayce, L., & Davies, approaches to schizophrenia (pp. 57-66). H., Mors, O., et al. (1999). Effects of E. (2006). Prejudice and schizophrenia: London: Routledge. family history and place and season of A review of the 'mental illness is an birth on the risk of schizophrenia. New Read, J. (2004b). Does 'schizophrenia' exist? illness like any other' approach. Acta England Journal of Medicine, 340(8), Reliability and validity. In J. Read, L. Psychiatrica Scandinavica, 114(5), 603-608. Mosher & R. Bentall (Eds.), Models 303-318. doi: http://dx.doi.org/10.1111/ Mosher, L., Gosden, R., & Beder, S. (2004). of madness: Psychological, social and j.1600-0447.2006.00824.x biological approaches to schizophrenia Drug companies and schizophrenia: Read, J., Mosher, L., & Bentall, R. (2004a). (pp. 43-56). London: Routledge. Unbridled capitalism meets madness. In Models of madness: Psychological, J. Read, L. Mosher & R. Bentall (Eds.), Read, J. (2004c). A history of madness. In social and biological approaches to Models of madness: psychological, J. Read, L. Mosher & R. Bentall (Eds.), schizophrenia. London: Routledge. social and biological approaches to Models of Madness: Psychological, Read, J., Mosher, L., & Bentall, R. (2004b). schizophrenia (pp. 115-130). Hove, UK: Biological and Social Approaches to 'Schizophrenia' is not an illness. In J. Brunner-Routledge. Schizophrenia (pp. 9-20). London: Read, L. Mosher & R. Bentall (Eds.), Routledge. Moskowitz, A., Schafer, I., & Dorahy, Models of madness: Psychological, M. J. (2008). Psychosis, trauma and Read, J. (2004d). The invention of social and biolgical approaches to dissociation: Emerging perspectives on 'schizophrenia'. In J. Read, L. Mosher & schizophrenia. London: Routledge. severe psychopathology Hoboken, NJ: R. Bentall (Eds.), Models of Madness: Read, J., Perry, B., Moskowitz, A., & Wiley-Blackwell. Psychological, Social and Biological Connolly, J. (2001). The contribution of Approaches to Schizophrenia (1st ed., Myers, J., & Bean, L. (1968). A decade later: early traumatic events to schizophrenia pp. 21-34). London: Routledge. A follow-up of Social Class and Mental in some patients: A traumagenic Illness. New York: Wiley. Read, J. (2004e). Poverty, ethnicity and

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neurodevelopmental model. Psychiatry: symptoms in a nonclinical population Psycholgical, Social and Integrative Interpersonal and Biological Processes, at age 12 years. Archives of General Approaches, 2(1), 50-69. 64(4), 319-345. doi: http://dx.doi. Psychiatry, 66(527-536). Weinmann, S., Read, J., & Aderhold, V. org/10.1521/psyc.64.4.319.18602 Sharfstein, S. (2005). Big Pharma and (2009). Influence of antipsychotics on Read, J., Seymour, F., & Mosher, L. (2004). American psychiatry: The good, the mortality in schizophrenia: Systematic Unhappy families. In J. Read, L. Mosher bad, and the ugly. Psychiatric News, review. Schizophrenia Research, 113(1), & R. Bentall (Eds.), Models of madness: 40(16), 3-4. 1-11. doi: http://dx.doi.org/10.1016/j. psychological, social and biological Shevlin, M., Dorahy, M., & Adamson, schres.2009.05.018 approaches to schizophrenia (pp. 253- G. (2007). Trauma and psychosis: An Wells, J. E., Oakley Browne, M. A., Scott, K. 268). London: Routledge. analysis of the National Comorbidity M., McGee, M. A., Baxter, J., Kokaua, J., Read, J., van Os, J., Morrison, A., & Ross, Survey. American Journal of Psychiatry, et al. (2006). Te Rau Hinengaro: the New C. (2005). Childhood trauma, psychosis 164(1), 166-169. doi: http://dx.doi. Zealand Mental Health Survey: overview and schizophrenia: A literature review org/10.1176/appi.ajp.164.1.166 of methods and findings. Australian & with theoretical and clinical implications. Shevlin, M., Murphy, J., Houston, J., New Zealand Journal of Psychiatry, Acta Psychiatrica Scandinavica, 112(5), & Adamson, G. (2009). Childhood 40(10), 835-844. 330-350. doi: http://dx.doi.org/10.1111/ sexual abuse, early cannabis use, Werner, S., Malaspina, D., & Rabinowitz, j.1600-0447.2005.00634.x and psychosis: Testing the effects of J. (2007). Socioeconomic status at birth Ross, C. (2010). DSM-5 and the 'Psychosis different temporal orderings based on the is associated with risk of schizophrenia: Risk Syndrome': Eight reasons to reject National Comorbidity Survey. Psychosis: Population-based multilevel study. it. Psychosis: Psychological, Social and Psychological, Social and Integrative Schizophrenia Bulletin, 33(6), 1373- Integrative Approaches, 2(2), 107-110. Approaches, 1(1), 19-28. 1378. doi: http://dx.doi.org/10.1093/ Ross, C., & Pam, A. (1995). Pseudoscience Shooter, M. (2005). Dancing with the schbul/sbm032 in biolgical psychiatry: Blaming the devil? A personal view of psychiatry's Wheaton, B. (1978). The sociogenesis body. New York: Wiley. relationship with the pharmaceutical of psychiatric disorder. American Ross, C., & Read, J. (2004). Antipsychotic industry. Psychiatric Bulletin, 29, 81- Sociological Review, 43, 383-403. medication: Myths and facts. In J. Read, 83. Wilkinson, R., & Pickett, K. (2009). The L. Mosher & R. Bentall (Eds.), Models Strauss, J., Kokes, R., Ritzler, B., Harder, D., spirit level: Why more equal societies of madness: Psychological, social and & VanOrd, A. (1978). Patterns of disorder almost always do better. London: Allen biological approaches to schizophrenia in first admission psychiatric patients. Lane. (pp. 101-114). London: Routledge. Journal of Nervous and Mental Disease, Zito, J. M., Safer, D. J., DosReis, S., Gardner, Ruggeri, M., & Tansella, M. (.2009 ). 166(9), 611-623. doi: http://dx.doi. J. F., Magder, L., Soeken, K., et al. The interaction between genetics and org/10.1097/00005053-197809000- (2003). Psychotropic practice patterns epidemiology: the puzzle and its pieces. 00001 for youth: a 10-year perspective. Archives Epidemiologia e Psichiatria Sociale, Talala, K., Huurre, T., Aro, H., Martelin, of Pediatrics & Adolescent Medicine, 18, 77-80. T., & Prattala, R. (2009). Trends in 157(1), 17-25. Rushing, W., & Ortega, S. (1979). socio-economic differences in self- Zubin, J., & Spring, B. (1977). Vulnerability: Socioeconomic status and mental reported depression during the years a new view of schizophrenia. Journal of disorder. American Journal of Sociology, 1979-2002 in Finland. Social Psychiatry Abnormal Psychology, 86(2), 103-126. 84, 1175-1200. and Psychiatric Epidemiology, 44(10), 871-879. doi: http://dx.doi.org/10.1007/ Salmond, C., & Crampton, P. (2000). s00127-009-0009-5 Sections of this paper are based directly Deprivation and health. In P. Howard- on corresponding sections of a previous Chapman & M. Tobias (Eds.), Social Thompson, A., Stuart, H., Bland, R., Arboledo-Florez, J., Warner, R., & review by the same author (Read, 2004e), inequalities in health: New Zealand which the current paper updates. 1999 (pp. 9-24). Wellington: Ministry Dickson, R. (2002). Attitudes about of Health. schizophrenia from the pilot site of the WPA worldwide campaign against Corresponding Author: Samele, C., van Os, J., McKenzie, K., the stigma of schizophrenia . Social Wright, A., Gilvarry, C., Manley, C., et Dr John Read Psychiatry and Psychiatric Epidemiology, al. (2001). Does socioeconomic status 37, 475-482. Department of Psychology predict course and outcome in patients The University of Auckland with psychosis? Social Psychiatry & Tosato, S., & Lasalvia, A. (2009). The Psychiatric Epidemiology, 36(12), 573- contribution of epidemiology to defining Private bag 92019 the most appropriate approach to genetic 581. Auckland 1142, research on schizophrenia. Epidemiologia Sanders, A., Duan, J., Levinson, D., Shi, e Psichiatria Sociale, 18, 81-90. New Zealand. J., He, D., Hou, C., et al. (2008). No significant association of 14 candidate Verdoux, H., & Tournier, M. (2004). [email protected] genes with schizophrenia in a large Cannabis use and risk of psychosis: European ancestry sample: implications An etiological link? Epidemiologia e for psychiatric genetics. . Americam Psichiatria Sociale, 13, 113-119. Journal of Psychiatry, 165(4), 497-506. Warner, R. (1985). Recovery from Schreier, A., Wolke, D., Thomas, K., schizophrenia. London: Routledge. Horwood, J., Hollis, C., Gunnell, D., Weinmann, S., & Aderhold, V. (2010). © This material is copyright to the New Zealand et al. (2009). Prospective study of peer Antipsychotic medication: Mortality Psychological Society. Publication does not victimization in childhood and psychotic and neurodgeneration. Psychosis: necessarily reflect the views of the Society.

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