Having seen that both recovery rates in schizophrenia and rehabilitative efforts expended on the mentally ill tend to diminish during the depression, the question of cause and effect remains to be addressed. Do the patients fail to get better because nobody bothers to treat them, or does nobody bother to treat them because they fail to get better? Earlier in this chapter it was suggested that unemployment has a direct psychological impact on those who are out of work, including the mentally ill, and could thus stand in the way of recovery from psychosis. Can we rule out the additional possibility, implicit in Marxist theory, that a labor glut so diminishes the political incentive to rehabilitate the mentally
ill that treatment efforts and community integration are discouraged, thereby worsening recovery rates?
Like most “chicken and egg” questions, this one is probably unanswerable. The events occurring at times of major policy change are so tightly intertwined that no one factor can be recognized as causative. Kathleen Jones, for example, sees three components to the postwar British social psychiatry revolution—the Open-Door Movement, the introduction of the antipsychotic drugs and legislative developments.
From the point of view of the therapy or of public policy, the coincidence of these three movements was fortunate, since each reinforced the other. From the point of view of social analysis, it was less so, since it made it impossible to trace cause and effect with any confidence. The three strands of development crossed and re-crossed, becoming so interwoven that it will probably never be possible to determine what influence each had.37
Certainly there is no indication, in the case of postwar Britain, that psychiatrists, noting greater success rates, dragged politicians unwillingly along. As early as 1948, the National Health Service Act established local authority mental health departments that assumed responsibility for community care for the mentally ill; in 1954 a parliamentary debate pushed for further modernization of mental health services and hospitals; and, in the same year, a Royal Commission was formed to consider legislative reforms that would facilitate community care.38 All this
occurred before the widespread introduction of the antipsychotic drugs and contemporaneous with the earliest moves to open the doors of the psychiatric wards. It seems probable that the political incentive to put into practice advances in psychiatric care and to increase the rehabilitation of the mentally ill was already there—stimulated by the urgent need for labor.
The question of cause and effect has a practical aspect. If it were possible artificially to maintain employment for the mentally disabled during hard times, would recovery rates improve (and admission rates and treatment costs decline), or would the social and political consensus existing during the depression limit the potential for improvement in the course of psychosis? It seems quite possible, in fact, that the effect of the social and political forces would be to obstruct the development of preferential employment for mental patients. Since the earliest days of institutions, workers in the regular labor force have objected to the unfair competition of inmates’ labor during periods of unemployment. Charles Dickens illustrates this point by contrasting the prisons of labor-starved America in the 1840s with those of Britain, where a surplus of workers existed.
America, as a new and not over-populated country, has, in all her prisons, the one great advantage, of being able to find useful and profitable work for the inmates; whereas, with us, the prejudice against prison labour is naturally very strong, and almost insurmountable, when honest men who
have not offended against the laws are frequently doomed to seek employment in vain. Even in the United States, the principle of bringing convict labour and free labour into a competition which must obviously be to the disadvantage of the latter, has already found many opponents, whose number is not likely to diminish with access of years.39
Here, in a nutshell, is the antagonism between unemployment and rehabilitation and recovery in mental illness.
More recent examples may readily be found. In the 1930s, efforts were made to introduce into British psychiatric hospitals methods of work therapy designed (by Dr Herman Simon of Gütersloh, Germany) to discourage “idleness or fatuous madness.” The failure of these efforts is explained by David Clark:
The world-wide depression of the 1930s may have made it difficult to justify diverting work to hospital patients when fit men outside were unemployed.40
In modern times, sheltered workshops in the United States, which generally provide employment for the disabled by contracting for piece-work with industry, face similar difficulties. During a business recession, fewer contracts are available and disabled workers have to be laid off. Alternatively, the workshops can bid to complete contracts for less than the actual cost. This makes them reliant upon government subsidies that are liable to be cut back as the depression deepens. Some workshops go bankrupt, others find that their attempts to subsidize their programs and under-bid for contracts are opposed by labor unions. Government sponsored job programs, furthermore, tend to concentrate on finding work for higher-functioning workers as unemployment mounts. All in all, it seems likely that, despite the best efforts and intentions of mental health professionals, it may not be possible completely to overcome the negative effects of the business slump on the course of schizophrenia.
LABOR DYNAMICS
Recovery from schizophrenia may worsen in the depression, it seems, because unemployment directly affects people with schizophrenia and because the reduced demand for labor results in a deterioration of rehabilitation and reintegration efforts. Economic hardship in the depression may also affect people who suffer from psychosis. We can explore just how powerful is the effect of labor dynamics on the course of schizophrenia by looking beyond the effects of the business cycle to broader relationships between the utilization of labor and outcome in schizophrenia. Specifically, we may predict:
• If one gender is less severely affected by labor market forces, members of that gender will tend to achieve better outcome in schizophrenia.
• If one social class is more affected by the rigors of the labor market, that class should experience poorer outcome in schizophrenia.
• Outcome from schizophrenia will be better in industrial nations with continuous full employment unaffected by cyclical changes.
• The course of schizophrenia will be more benign in non-industrial societies where wage labor and unemployment are uncommon.
These predictions allow us to discriminate, to a certain extent, between the effects of the labor market and of economic hardship—only in some of these instances can we expect economic hardship to produce the same direction of change in the course of schizophrenia. Let us see how accurate are these predictions.
GENDER DIFFERENCES IN RECOVERY FROM