Recovery From Schizophrenia: Psychiatry And Political Economy

TREATMENT 273One might imagine that there are few people in the community who wouldopen up their homes to acutely ill people in this way. When a program of thistype was launched in Boulder, Colorado, however, through a combination ofnewspaper articles and advertising, a hundred people called showing an interest inthe program in the first month, and half-a-dozen homes were selected within afew weeks.INTENSIVE COMMUNITY SUPPORTProviding non-alienating settings for acute treatment is an important part of thespectrum of community services. Another necessary element is preventing relapseand admission for acute treatment in the first place. A highly successful way ofachieving this is to follow people with the most severe forms of psychotic illnessso closely in the community—providing support at every step—that acute relapseis more or less eliminated. Leonard Stein, an American community psychiatrist,Mary Ann Test, a social worker, and their colleagues in Madison, Wisconsin, putsuch a program into effect in the 1970s. Their approach later came to be termed“assertive community treatment.” A similar program is provided now by themental health center in Madison, with leadership from psychiatrist, RonDiamond. Available 24 hours a day, seven days a week, mental health staff visitpatients in their own homes. They help their clients with long-standing mentalillness learn to do laundry, shopping, cooking, grooming and budgeting. Theyassist them in finding work and in settling disputes with landlords. If a patientdoes not show up for work or treatment one day, the staff member goes to his orher home to discover the reason. Staff help patients to expand their social livesand they provide support to the patients’ families. Early signs of the return ofpsychosis are immediately detected and lead to active treatment measures. Inessence, the patient is watched and helped as closely as he or she would be onmany hospital wards, but the treatment is provided instead in the patient’s ownneighborhood. This type of daily practical help and advocacy has come to betermed “case management.”When these measures fail, the patient may be admitted briefly to hospital; sucha move is rarely necessary, however. In a study of the course of illness in patientsreferred for admission to hospital with a severe psychiatric problem, it was foundthat nearly all of those randomly assigned to the Stein and Test intensive casemanagement program in Madison could be treated without hospital care; of thepatients assigned to standard outpatient care, on the other hand, nearly all wereinitially treated in hospital. At the end of a year the rate of readmission to hospitalwas six per cent for clients of the intensive community treatment team, incontrast to 58 per cent for patients in routine outpatient care. Mobile andintensive community treatment had put a stop to the revolving door.The clients in this program reaped other benefits. Compared with the patientsin standard community care, they had fewer symptoms, greater selfesteem andwere more satisfied with their lives after one year of treatment. They were more