Recovery From Schizophrenia: Psychiatry And Political Economy

180 THE POLITICAL ECONOMY OF SCHIZOPHRENIAnon-psychotic, senile mental disorder. One hundred thousand of these patientswere transferred directly into nursing home care from state mental hospitals; morewere admitted there after an interim period in another nursing home, in hospitalor in the community. 59 In 1987 the US Congress mandated that states screenpotential residents to ensure that they were not being inappropriately placed innursing homes. In most states this has resulted in the reduction of the placementof the mentally ill in such units-only those with concomitant physical disabilityare now being admitted. 60 In at least one US state, however, the stategovernment has skirted the Congressional mandate and has encouraged nursinghomes to admit young, physically healthy, mentally ill people. A 2002 New YorkTimes article revealed that as many as 100,000 people with mental illness may behoused in such units in New York state with the approval of Governor Pataki’sadministration. The Times reporter described these unregulated wards as“reminiscent of old-style institutions.” 61 Patients are rarely allowed outside; theysit idle or pace, do jigsaw puzzles, and crowd round the locked elevator doorswhenever anyone leaves or enters. In the Orwellian language of the statebureaucrats, these nursing home wards are termed “neurobiological units,” andadministrators claim that they are not locked but “key-operated.” 62Many people with schizophrenia are elderly or in poor health and so, in thoseparts of the country where the states have followed the Congressional mandate,they still constitute two to three per cent of the US nursing home population. 63With this population having expanded greatly in recent decades, this means thatat least 40,000–50,000 people with schizophrenia are housed in these settings.If we add to these numbers another 45,000–65,000 people with schizophreniaresident in state, county, private and Veterans Administration hospitals, 64 and ifwe accept the estimate that there are around 1,275,000 people with schizophreniain the United States, 65 we are forced to the discomforting conclusion that at leasta third of Americans with schizophrenia are to be found in institutions, ininadequate community settings, in jail, prison or on the streets (see Table 8.3). Onthe positive side, because the number of mentally ill people among the homeless,in hospital and in nursing homes has decreased, this proportion is smaller than inthe early 1980s. Nevertheless, fewer than seven out of ten people withschizophrenia in the United States are likely to be living in anything resembling afamily home or domestic environment. We need to increase this number if weare to see an improvement in outcome from schizophrenia in America.RESTRAINTS AND SECLUSIONWe should not assume that the patients who are in hospital are necessarily in idealtherapeutic environments. Their conditions of confinement may be quite harsh.Although both restraints and seclusion, for example, have proved to be largelyunnecessary in British practice, their use has been commonplace in hospitals inthe United States. A 1979 report indicated that 44 per cent of patients on an acuteadmission unit in California were locked up in seclusion for varying periods of