Recovery From Schizophrenia: Psychiatry And Political Economy

192 THE POLITICAL ECONOMY OF SCHIZOPHRENIAschizophrenia is treated through marginal institutions with a social expectationthat all concerned are to blame and that the condition is incurable. Thesedifferences in the status, integration and role of the mentally ill may well accountfor the distinctly worse outcome for schizophrenia in industrial societies.This constellation of problems has been described before, however; it isencompassed by the concept of alienation. Marx writes of people in industrialsociety becoming alienated from the process of working and the product of theirwork, from other people and from their own human qualities. 131 Modernpsychologists emphasize that alienation includes a profound sense ofmeaninglessness and powerlessness. 132How does this apply to the person with schizophrenia? In the stigma of mentalillness, the most debased status in our society, we see the utmost in painfulestrangement of one human from another; and in the person with schizophrenia’sown acceptance of this same dehumanized stereotype we witness the loss of his orher sense of fully belonging to humankind. It is in the menial jobs that thementally ill are most likely to find—dishwashing, envelope-stuffing, day-laboring—that work is most dehumanizing and alienation is most severe. But the morecommon fate of the person with schizophrenia—unemployment—is even worse.To stand bored and idle, to be unable to provide for oneself, to fulfill no useful socialfunction, to be of little value to oneself or others—these are the ultimate inalienation—a confrontation with the existential concern of meaninglessness.In one study, when people in community treatment for psychosis in Boulder,Colorado, were interviewed about their lives, their principal complaints were ofboredom and (among the men) unemployment—both rated as much moreproblematic than symptoms of mental illness. 133 People with psychosis, in fact,score lower than any other group on the Purpose-in-Life Test 134 —apsychological measure used to detect alienation and meaninglessness. Manyprofessionals suspect that the high prevalence of drug and alcohol abuse amongthe mentally ill—30–40 per cent of most samples 135 —is in part a consequence ofthe empty lives that many patients lead. In a study of substance use among thementally ill in the Boulder community, we found that those with the fewestplanned activities were the heaviest marijuana users, giving “boredom” as theprimary reason for drug use. 136Decades ago, when we were shifting the locus of care from the hospital to thecommunity, we found ways to combat what we called at that time theinstitutional neurosis—the posturing, the restless pacing, incontinence andunpredictable violence that were bred by the restrictions, regimentation andemptiness of hospital life. Humanizing the hospital wards and establishing“therapeutic communities,” which changed the power relationships between staffand patients and involved patients in ward management (as described inChapter 4), led to a reversal of this institutionally ingrained behavior. It now appearsthat we have traded the earlier institutional neurosis for a new existential neurosisthat may similarly stand in the way of recovery from the original psychotic illness.It seems likely, however, (and I will discuss this in greater detail in Chapter 12) that