Recovery From Schizophrenia: Psychiatry And Political Economy

98 DEINSTITUTIONALIZATIONbecame, to a greater degree, a matter of social policy. The extent of psychiatricinstitutional care now appeared to be largely a reflection of two factors. One wasthe national, political commitment to the quality and universality of health andwelfare provisions (of which infant mortality is an indicator). The other, since theantipsychotic drugs are of little benefit in the care of senile organic psychosis, wasthe proportion of the elderly in the general population.Deinstitutionalization, in some circumstances a sign of progressive effortstowards community care and rehabilitation of the mentally ill, may elsewherehave indicated the opposite—abrogation of responsibility for the welfare of asegment of the poor. In the United States in the 1970s, where health and welfareprovisions for the destitute were not well developed, the small numbers ofavailable mental hospital beds represented a refusal to provide adequate psychiatrictreatment for the indigent mentally ill. In Sweden, on the other hand, a politicalcommitment to adequate health and welfare provisions coupled with theexistence of a large elderly population led to a substantially greater use of mentalhospitals. Each of the other Scandinavian countries, like Sweden, maintainedcomprehensive health and welfare services, low infant mortality rates andsubstantial numbers of psychiatric hospital beds. Of these four countries Denmarkand Norway, with the greatest labor shortages until the mid-1970s, preservedrelatively low rates of mental hospital use and the most highly developedcommunity treatment programs. 77It is evident from the figures in Table 4.3 that it was not only the laborshortage in the Eastern Bloc countries in the 1970s that led to their minimal use ofpsychiatric institutions but also the underdevelopment of their health services ingeneral (witness their high infant mortality rates) and the low proportion of theelderly in the general population. Nevertheless, we know that the labor shortagein these countries, particularly Russia and Poland, at that time led to a very greatemphasis on work therapy, intensive community rehabilitation efforts, greateracceptance of the mentally ill in the community and the workplace and efforts tokeep the elderly productive. 78Full employment, then, may no longer be a major factor determining the sizeof mental hospital populations but it may be an important influence on thecharacteristics of community treatment and the adequacy of rehabilitative efforts.Where the surplus population is large, the conditions established for the personwith a psychotic illness tend to be least conducive to his or her recovery. Wherethe labor of the marginally productive is in demand, there shall we find the mosthighly developed community treatment programs and the most humane hospitalconditions. We shall see to what extent these factors influence the course ofschizophrenia.