Recovery from Schizophrenia: Psychiatry and Political Economy
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Recovery from Schizophrenia Recovery from Schizophrenia, from its first publication, was acclaimed as a work of major importance. It demonstrated convincingly, but controversially, how political, economic and labor market forces shape social responses to the mentally ill, mold psychiatric treatment philosophy, and influence the onset and course of one of the most common forms of mental illness. In this revised and updated third edition, Dr Warner analyzes the latest research to extend the conclusions of the original work, and tells us whether conditions and outcome for people with schizophrenia are getting better or worse for people in Britain and America. In addition, he: • Critiques recent approaches to preventing the occurrence of schizophrenia. • Suggests innovative strategies for advancing the economic situation of people with mental illness. • Describes the latest advances in the rehabilitation of people with schizophrenia. • Provides a guide on how to combat the stigma of mental illness at the local and national level. Recovery from Schizophrenia’s radical analysis of the factors affecting the outcome of schizophrenia is essential reading for all psychiatrists, mental health professionals, mental health advocates, social workers, rehabilitation personnel, and psychologists. Richard Warner is the Medical Director of the Mental Health Center of Boulder County, Colorado and Clinical Professor of Psychiatry and Adjunct Professor of Anthropology at the University of Colorado. Recovery from Schizophrenia Psychiatry and Political Economy Third Edition Richard Warner HOVE AND NEW YORK First edition published 1985 by Routledge 11 New Fetter Lane, London EC4P 4EE Second edition published 1994 by Routledge Reprinted 1997 by Routledge Third edition published by Brunner-Routledge 27 Church Road, Hove, East Sussex BN3 2FA Simultaneously published in the USA and Canada by Brunner-Routledge 29 West 35th Street, New York NY 10001 Brunner-Routledge is an imprint of the Taylor & Francis Group This edition published in the Taylor & Francis e-Library, 2005. “To purchase your own copy of this or any of Taylor & Francis or Routledge’s collection of thousands of eBooks please go to www.eBookstore.tandf.co.uk.” Copyright © 2004 Richard Warner All rights reserved. No part of this book may be reprinted or reproduced or utilized in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. This publication has been produced with paper manufactured to strict environmental standards and with pulp derived from sustainable forests. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data Warner, Richard, 1943– Recovery from schizophrenia/Richard Warner.—3rd ed. p. cm. Includes bibliographical references and index. ISBN 0-415-21266-9 (Print Edition) 1. Schizophrenia—Treatment—Political aspects. 2. Schizophrenia—Treatment—Economic aspects. 3. Schizophrenia—Treatment. 1. Title. RC514.W24 2003 362.2′ 6—dc2l 2003008633 ISBN 0-203-42087-X Master e-book ISBN ISBN 0-203-44259-8 (Adobe eReader Format) ISBN 0-415-21266-9 (hbk) ISBN 0-415-21267-7 (pbk) To those who suffer from schizophrenia Contents Acknowledgments vi Introduction viii PART I Background 1 1 What is schizophrenia? 2 2 Health, illness and the economy 29 Part II The political economy of schizophrenia 53 3 Recovery from schizophrenia 54 4 Deinstitutionalization 80 5 Madness and the Industrial Revolution 102 6 Labor, poverty and schizophrenia 127 7 Schizophrenia in the Third World 148 8 The person with schizophrenia in Western society 172 9 The incidence of schizophrenia 195 PART III Treatment 219 10 Antipsychotic drugs: use, abuse and non-use 220 11 Work 246 12 Desegregating schizophrenia 266 Notes 301 Bibliography 369 Author index 374 Subject index 374 Acknowledgments Several people were kind enough to give me criticism and encouragement when some of the ideas in this book were first drafted in the form of a long article. Among these reviewers were John Strauss, John Wing, Loren Mosher, Solomon Goldberg, Lewis Wolberg, Bernard Bloom and Maxwell Jones. I am most grateful for their advice. I am also indebted to those who have discussed this research with me and reviewed sections of the book. I have received valuable critiques from the following colleagues in various departments of the University of Colorado: Robert Freedman, Thomas Mayer, Edward Greenberg, and Paul Shankman. Jani Little and Charles Judd have been invaluable statistical advisors and Gary McClelland provided advice and instruction about probability theory and the prevention of schizophrenia. At the Mental Health Center of Boulder County, my associates Phoebe Norton and Ruth Arnold have made useful comments on sections of the manuscript. Julian Leff and Andrew Scull carefully reviewed large sections of the work and made many helpful suggestions. I gained a great deal from discussions with Loren Mosher, Julian Leff, Paul Polak, Robert Freedman, James Mandiberg and Ezra Susser. Robert Freedman contributed to the development of the theory about the occurrence of schizophrenia in Chapter 9. Much of the discussion in Chapter 10 about the economic advancement of the mentally ill in the community is a result of my collaboration with Paul Polak. Ezra Susser has helped me with epidemiological advice on many of the themes in the book. Sue Estroff and Joe Morrisey have often helped with ideas, information and insights. My research collaboration with Dawn Taylor, Giovanni de Girolamo, Peter Huxley and Sherrill Evans, among others, has allowed many of the ideas in the book to be tested. Many colleagues associated with the World Psychiatric Association global anti-stigma program have increased my understanding of how to tackle stigma; they include Hugh Schulze, Everett Rogers, Corinne Shefner-Rogers, Otto Wahl, Heather Stuart and Norman Sartorius. Gyles Glover, of the University of Durham, gathered the data on National Health Service expenditure on mental illness, which are referred to in Chapter 6. I have been fortunate to work with many creative and talented colleagues at the Mental Health Center of Boulder County in the past quarter-century. Their vii devotion to excellence in creating innovative services for people with mental illness has been an inspiration. The leadership and human values of Phoebe Norton has made possible the formation of a system of care that embodies many of the principles set out in this book. A great deal of credit is due to Marilyn Rothman, the librarian who, with great energy and skill, helped me assemble the many sources cited here. Jennifer Johnson cheerfully and efficiently located recent articles on outcome from schizophrenia for this edition. I am especially grateful to my wife, Lucy Warner, for her unflagging support, astute criticism and editorial advice. Gary Sims, who created the cover art used for each edition of this book, died in 1993, loved and missed by many. I thank his parents for their permission to use the design for the paperback cover of this edition. The following figures are reprinted from other sources by permission of the publisher or author. Figure 1.3 is taken from Gottesman, I.I., Schizophrenia Genesis: The Origins of Madness, New York, W.H.Freeman, 1991, p. 96, ©1991 Irving I.Gottesman. Figure 2.1 is taken from Brenner, M.H., “Fetal, infant and maternal mortality during periods of economic instability,” International Journal of Health Services, 3:145–59, 1973, p. 153, ©1973 Baywood Publishing, Farmingdale, New York. Figure 5.1 is taken from Bockoven, J.S., Moral Treatment in Community Mental Health, New York, Springer, 1972, p. 56, ©1972 J.Sanbourne Bockoven. Material in Chapters 3 and 6 has previously been published in Warner, R., “The influence of economic factors on outcome in schizophrenia,” Psychiatry and Social Science, 1:79–106, 1981, ©1981 Universitetsforlaget, Oslo. The research at the end of Chapter 4 has previously been published in Warner, R., “The effect of the labor market on mental hospital and prison use: an international comparison,” Administration in Mental Health, 10:239– 58, 1983, ©1983 Human Sciences Press, New York. Chapter 7 has previously appeared in essentially similar form as Warner, R., “Recovery from schizophrenia in the Third World,” Psychiatry, 46: 197–212, 1983, ©1983 William Alanson White Psychiatric Foundation, Washington, DC. Some of the material on combating stigma has been seen before in Warner, R., The Environment of Schizophrenia, ©2000 Brunner- Routledge, London. Introduction Does the way we make our living or the level of economic development of our country affect whether or not we become mentally ill? Does social class or the state of the economy influence whether people with schizophrenia recover from their illness? Has industrial development affected the number of people with schizophrenia who become permanently and severely disabled—lost to their families, costly to the community and leading lives of emptiness and degradation? These questions are at the heart of this book. My original intent was to uncover what the natural course of schizophrenia had been before the antipsychotic drugs were introduced, but this simple goal led to the realization that some current beliefs about the illness, widely accepted in psychiatry, are not accurate. We may well have been