Recovery From Schizophrenia: Psychiatry And Political Economy

WHAT IS SCHIZOPHRENIA? 9complete symptomatic recovery. There can be no doubt, though, that the courseof the illness in Bleuler’s patients was much more benign than in Kraepelin’shospital in Munich. So much so, that Bleuler was able to assert thatthe therapy of schizophrenia is one of the most rewarding for the physicianwho does not ascribe the results of the natural healing processes of psychosisto his own intervention. 11It would be hard to find in modern psychiatry such an optimistic view of thenatural course of schizophrenia.Bleuler’s treatment methodsWhy should the outcome for Bleuler’s patients have been so superior? He maywell have broadened the diagnosis of schizophrenia to include some less severelydisturbed patients. But it is also likely that Bleuler was too modest about the valueof treatment, and that his methods of management maximized the chances of hispatients’ recovery. The description of his treatment methods from the first decadeof the twentieth century reads like a model of the approaches introduced a halfcenturylater in the social psychiatry revolution of postwar northern Europe (tobe described in Chapter 4) or like the principles of humane care abandoned half acentury earlier at the end of the moral-treatment era (described in Chapter 5).Institutional care, for instance, was to be minimized. “It is preferable to treatthese patients under their usual conditions and within their habitualsurroundings,” Dr Bleuler insisted. “The patient should not be admitted tohospital just because he suffers from schizophrenia, but only when there is adefinite indication for hospitalization.” Furthermore, “one can consider it anestablished rule that earlier release produces better results.” 12 If the patient cannotreturn to his own family, “the care he may receive from a strange family oftenserves as an adequate substitute.” 13 In pursuing this policy of active communityrehabilitation Bleuler may have been aided by the low levels of poverty andunemployment in Switzerland at that time. It is certain, at any rate, that hisdischarge policies were much more liberal than those of Kraepelin.The return to an appropriate occupation, Bleuler believed, was vital to thepatient’s health. “Idleness facilitates the predomination by the complexes over thepersonality,” he argued, “whereas regulated work maintains the activity of normalthinking.” 14 But he emphasized that “faultless performance can hardly beexpected and the unavoidable rebukes can greatly endanger the entire pleasurethat the patients take in their work.” 15 Dr Bleuler recognized that a number ofother stresses might threaten the patient’s recovery—too much responsibility atwork, for example, family troubles or a sense of failure.Within the institution close attention was to be given to the quality of thepatient’s environment. “Good surroundings have a very different influence on thepatient than unpleasant and noisy ones.” 16 The use of mechanical restraints was