Recovery From Schizophrenia: Psychiatry And Political Economy

WHAT IS SCHIZOPHRENIA? 25One thing only is certain in this field: thousands, if not millions, of family membersof people with schizophrenia in the West have suffered shame, guilt and stigma asa consequence of the widespread acceptance of such theorizing. Parents have notonly suffered the pain of seeing their child’s personality change and his or herambitions destroyed by illness, they have also felt blamed, directly or indirectly, forcausing the condition. Family members may carry the burden of living withsomeone whose actions can be unpredictable and distressing and whose emotionalresponses are unrewarding, but they may also receive little empathy and supportfrom therapists who are liable to censure and distrust them. The reactions ofsociety to the person with schizophrenia and his or her relatives may be sufficient,of themselves, to produce distorted patterns of family interaction.Stress—domestic and non-domesticIf we study the family, not for formative influences building a vulnerability toschizophrenia, however, but for current household stresses influencing the courseof an already established illness, a far more clear-cut picture emerges. People withschizophrenia living with relatives (by birth or marriage) who are critical orsmothering have a much higher relapse rate, according to research from severalcountries and cultures, than those who live with relatives who are less hostile orintrusive. 75 Further studies have shown that relatives who are less critical andover-involved exert a positive therapeutic effect on the person with schizophrenia—their presence leading to a reduction in the patient’s level of arousal. 76 In thesame vein, people with schizophrenia who see their parents as being affectionateand undemanding have a low relapse rate if they are in contact with their parents,but tend to do poorly and relapse more often if they are not. 77 The benefits of alow-stress household on the relapse rate of people with schizophrenia appear tobe equally as strong as the effect of antipsychotic drugs treatment. 78There is no indication that the more critical and over-involved relatives are atall abnormal by everyday Western standards. It appears, in fact, that thehouseholds where there is more criticism and intrusiveness are those with patientswho have personality attributes that make them difficult to live with. 79 Theevidence suggests that the families in which people with schizophrenia do wellhave adapted to having a mentally ill person in the household by becomingunusually low-key and permissive. 80 In the developing world the picture isdifferent. A study conducted in Chandigarh, India, revealed that few relatives ofpeople with schizophrenia in this Third World city showed the same high levelsof criticism and over-involvement found to be common in the West. 81 TheseWestern responses to mentally disordered family members may be a product ofemotional isolation engendered by nuclear-family life, or the result of highachievement expectations placed on the mentally ill person. The decline ofextended-family living is largely a consequence of industrialization, andeducational and occupational achievement standards are higher in our advanced