Recovery From Schizophrenia: Psychiatry And Political Economy

242 TREATMENTschizophrenia, as they share many common features (see Chapter 1). A number ofstudies have shown that people with good-prognosis schizophrenia-like psychosishave a high incidence of manic-depressive illness among their relatives—a findingthat suggests that they may themselves suffer from an affective illness. 77 A historyof distinct, prior, extended episodes of pathologically elevated or depressed moodpoints towards a diagnosis of manic-depressive illness. Such patients can be treatedwith lithium carbonate or with another mood-stabilizer like carbamazepine(Tegretol) or sodium valproate (Depakote). In some instances a clear diagnosis isnot possible until the passage of time has revealed a characteristic course of theillness. In such cases withdrawal from medication and a wait-and-see approachmay be appropriate.MINIMIZING MEDICATION USEIn modern times, the deliberate treatment of schizophrenia without antipsychoticdrugs is seldom practiced, but the lessons learned from such approaches tell ushow treatment and living environments should be structured to require minimaldoses of antipsychotic medication. What must be provided is an opportunity forthe acutely ill person with schizophrenia to be cared for in a non-stressfulenvironment that maximizes the chance for a spontaneous remission orimprovement to occur.The settingThe characteristics of a therapeutic environment for people with schizophreniahave already been set down—warm, protective and enlivening without beingsmothering, over-stimulating or intrusive. In addition, as earlier chapters of thisbook have indicated, the patients should be allowed to maintain a valued social role,together with their status, dignity and a sense of belonging to the community atlarge. Patients must be able to stay in residential treatment long enough for theircondition to improve and to be free of urgency to move on. With a week’s stayin a private psychiatric hospital ward in the United States costing roughly thesame as a round-the-world trip, it is clear that extended, minimal-dosage caremust be provided in a low-cost, alternative community setting.Soteria House, mentioned earlier, offers a model for such communitytreatment. A large house in a San Francisco Bay neighborhood, Soteria providedaccommodation for six people with schizophrenia and two staff. “Recentlyadmitted, very psychotic residents receive a great deal of special one-to-one, ortwo-to-two attention,” wrote Loren Mosher and his associates, “and performanceexpectations are minimal.” 78 As residents became less psychotic they participatedmore actively in the therapeutic community-planning and performing householdtasks and working out interpersonal differences. Each pursued recreationalactivities of his or her own choice. When compared with the local community