Recovery From Schizophrenia: Psychiatry And Political Economy

276 DESEGREGATING SCHIZOPHRENIApatients, nevertheless, will have put an immense strain on the community supportsystem. Many hours of work will have been put into makeshift treatment plansthat have little hope of success.The number of patients that cannot be treated in the community is extremelysmall, however. On any day in the past decade in Boulder County, around fivepatients with psychosis are likely to be in long-term, public hospital care, placedthere by the mental health center. Another 15 mental health center patients withpsychosis are likely to be receiving medium- or short-term hospital treatment(lasting from a few days to three months) in a general hospital psychiatric ward orin a public psychiatric hospital, before returning to community care. 18 Thesepatients are drawn from a county population of 275,000 people and a caseload ofover 4,500 mental health center clients, over 700 of whom suffer from psychosis.The number of patients in long-term, non-forensic hospital care emerges as lessthan one per cent of all the patients with functional psychosis in treatment at themental health center.It is important to identify these few clients and arrange for them to receivehospital care as the humane course of treatment. This may be easier said thandone. Long-term hospital care in the United States is virtually a thing of the past.State budget cuts have so reduced hospital capacity that hospital staff feel obligedto discharge any patient who loses his or her symptoms of acute psychosisregardless of what the patient’s trajectory is likely to be after release. Communitymental health administrators must first fight to see a bare sufficiency of hospitalbeds funded; and then they must stand firm against the pressure to discharge fromthe hospital patients who cannot be properly treated once they leave.If community support services were provided on a truly comprehensive basis,we would only need small hospitals but they would serve a highly specializedfunction. Based on the experience in Boulder and elsewhere, only one or twohospital beds for adults (aged 18–65) would be needed for each 10,000 of thegeneral population. (Mental health staff working with the population of largecities might arrive at a higher estimate for the number of required hospital beds.States or countries with a mental illness statute that does not permit involuntaryoutpatient treatment would also need more hospital beds.) Some inpatients,however, would be resistant or unresponsive to treatment and locked doorswould be necessary. For the tiny handful of long-term inpatients hopes forimprovement would depend upon their being provided with work therapy, arange of recreational activities, skilled, humane care in small attractive units andaccess to a pleasant, open-air environment. In other words, they would be asunlike nursing homes as it is possible for such places to be.AN ALTERNATIVE TO LONG-TERM HOSPITALCAREOne reason that the number of patients in Boulder County in long-term hospitalcare is so low is because an open-door domestic alternative to hospital has been