Recovery From Schizophrenia: Psychiatry And Political Economy

274 DESEGREGATING SCHIZOPHRENIAlikely to be living independently and had spent less time in jail. 12 This wasaccomplished, furthermore, with no increase in social cost to the patient’s familyor the community; there was no increased burden of social disruption or suicidalgestures. 13A program at the Mental Health Center of Boulder County, based on theMadison model, provides similar services and achieves equivalent results. InBoulder, the 20 per cent of the agency’s clients who are suffering from psychosisand who have the greatest likelihood of relapse are assigned to an intensive casemanagement team. Caseloads are small; each therapist is responsible for only 12 to15 clients. The services they receive, when necessary, include:• daily, flexible, unscheduled contact,• twice daily medication administration,• daily monitoring of funds (the therapist may be payee for the client’s disabilitypension),• supervised and subsidized housing,• assistance with acquiring entitlements, housing and health care,• advocating for clients with social agencies and the criminal justice system,• ensuring that clients get adequate medical care for physical health problems.Because medication can be administered daily, few clients assigned to this teamreceive long-acting intramuscular (depot) antipsychotic drugs. Patients appreciatethis fact; almost none choose intramuscular medication, even though coming indaily for oral medication is a chore—a telling comment on the dislike that clientshave for the increased side effects associated with the past misuse of depotmedications. Patients with bipolar disorder show the greatest improvement afterassignment to the team, presumably because their lithium carbonate or othermood-stabilizing medication is carefully monitored. Clients whose mental illnessis complicated by drug and alcohol abuse also do better on this team; in part thisis because their money is often disbursed in modest daily amounts—too little toallow the recipient to get too drunk or high. Their illness, consequently, is lesssevere, their rent is paid regularly and they are no longer at risk of being admittedto hospital acutely psychotic, hungry and homeless halfway through the month.Before they were assigned to this intensive treatment team in 1984, 28 per cent ofthe initial sample of severely disturbed clients were revolving-door patients withseveral hospital admissions a year; six years later less than five per cent were in thisfrequent-admission category. With treatment, most of the group developed astable course of illness. Only four per cent of the cohort had originally been freeof hospital admissions over a two-year period; six years after assignment tointensive treatment nearly 60 per cent were this stable.The effectiveness of assertive community treatment has been demonstrated inmany studies conducted in different countries including the US, Sweden andAustralia. 14 Curiously, some major British studies have not found the approach tobe effective. 15 One reason for the disappointing results found by the British