Ley de Economía Popular y Solidaria y del Sector Financiero Popular

Stress may provoke a psychotic relapse in someone with schizophrenia (as discussed in Chapter 1). Both the boom and bust parts of the business cycle bring their own varieties of stress. In the depression they include loss of status, self- worth and independence for the unemployed, a sense of failure for those who slip down the social ladder, and economic hardship for many. People with schizophrenia living in the community are exposed to all these possible stresses and those with marginal levels of functioning are particularly at risk when jobs are in short supply.

Clinical experience shows us that economic uncertainty is a serious stress for many patients. As social security regulations were tightened during the early years of the Reagan administration, for example, many people with a stable psychotic disorder whose disability payments were abruptly terminated suffered relapses of their illness. The mental condition of many people with psychosis similarly becomes worse when their most basic needs are not provided for. In the United States, homeless male patients with schizophrenia are frequently admitted to hospital, hungry, dirty, sleepless and floridly psychotic. When, after some meals and a good night’s sleep, their mental state dramatically improves, hospital staff may claim that the patient has “manipulated” his way into free board and accommodation. More benign observers argue that the patient’s improvement is evidence of the efficacy of the dose of the antipsychotic medication that he received on admission. In fact, such patients often improve as readily without

Figure 6.4 Annual per capita National Health Service expenditure on mental illness (before 1987) and mental health services (after 1987) in England and Wales (first series) and England (last three series) in constant (1998) pounds

Source: The raw data were gathered from health service publications by Gyles Glover, University of Durham, and subsequently adjusted for annual inflation and population growth.

medication. The florid features of their psychosis on admission are an acute response to the stress of their poverty and deprivation.

We can estimate from the social recovery rates in Chapter 3 that 70 per cent of people with schizophrenia were unemployed at follow-up during the Great Depression—significantly more than after the Second World War. In recent years, again, it has become so common for people with schizophrenia living in the community to be out of work that mental health professionals rarely consider unemployment a significant stress for their patients. For many of these people with psychotic illness, however, the dreary round of days without purposeful activity, lives devoid of meaning and a social existence stripped of status are a constant strain. British unemployed men complain:

“You’re a drag on everybody else really.”

“Sometimes I get to walking up and down on the carpet.”

“…cannot be bothered to dae nowt, just feel like stopping in bed all day.”

“When you’re out of work you worry and don’t feel like eating.” “I go for a walk and try to do some reading if I can, but it’s very hard for me to get the brain functioning properly.”

“I’m so moody you know.”

“I thought, ‘What’s the bloody point of it all, anyway? What’s the reason for it all?’ Then you start to become, well, deranged.”

“I think you start to lose your identity in yourself…. There’s times when, well ‘What’s…what am I?’”3

Such responses are those of unemployed men who are not particularly susceptible to psychosis. The impact on people with schizophrenia can scarcely be less severe, and could well affect their recovery and relapse rates.

Indeed, the similarity of many features of chronic schizophrenia to the psychological effects of extended unemployment is striking. Anxiety, depression, apathy, irritability, negativity, emotional overdependence, social withdrawal, isolation and loneliness, and a loss of self-respect, identity and a sense of time—all these are common amongst the long-term unemployed.4 _{Compare these features,}

and the words of the British unemployed quoted above, with this description of schizophrenia:

Anergy, or disturbances of volition, have at times been incorrectly described as apathy…. Patients may be abnormally tired, fatigue easily, and experience clinical depression. The chronic schizophrenic may sit blankly for long periods, unaware of the passage of time…. He may remain in bed when he intended to look for a job, avoid or put off without reason any activity that is new, unfamiliar or outside of his routine…. Life is routine, constricted, empty. He may sleep most of the day, be awake most of the night. The chronic schizophrenic in the community may fear contact with strangers….

He may be unable to cope with…the complex demands of welfare departments.5

Although many of these “negative” features of schizophrenia are known to be made worse by the social deprivation of institutional care, they are nevertheless seen by psychiatrists as inherent aspects of the illness. (Hence the emphasis on the biological concept of “anergy” rather than the psychological attribute of “apathy”) Mental health professionals become frustrated by, and sometimes critical of, their patients’ dependency, incompetence and unreliability. To label such problems as biological deficits helps the professional cope with his or her frustrations, but it also increases the pessimism regarding treatment and the stigma that attaches to the patient. That such deficits are, to an extent, socially induced becomes apparent, however, when we read the words of this unemployed (non- psychotic) teenager:

“I feel outside of it…[unemployment] just makes me feel different. I really admire these guys who can get up and shave, and have breakfast, and make a journey to work, and come home again, and have meals-guys who can do all that in one day! I don’t know how they can manage it. When I’ve got to sign on, or anything like that, just do the one thing, it bugs me all day…. Or if I’ve got anything to do…say to catch a bus to go somewhere, it’s a real drag. We can’t seem to get with it.”6

The similarity in the emotional reactions of the unemployed and of people with psychosis was highlighted by a study conducted in the Great Depression. The level of negativity and pessimism about the future in large samples of the Scottish and Lancashire unemployed was found to be greater than that of groups of patients with psychotic depression and schizophrenia.7 _{If the unemployed are as}

distressed as hospitalized people suffering from psychosis, how can we hope that the unemployed people with psychosis will return to normal during hard times? In fact we may ask, as did the author of the study of the Scottish and Lancashire jobless, “why mentally distressed unemployed …do not become psychotic.”8

The answer is, of course, they may well do so. Brenner found that it was precisely that segment of the population that suffers the greatest relative economic loss during a depression—young and middle-aged males with moderate levels of education—that showed the greatest increase in rates of admission to New York mental hospitals for functional psychosis during an economic downturn. Prominent among these patients were people admitted for the first time with schizophrenia.9 _{We saw in Chapter 2 that the likeliest explanation for this effect}

was a true increase in the occurrence of psychosis secondary to the stresses of the economic recession and unemployment. In Chapter 9 we shall explore in more detail whether labor dynamics significantly affect the rate of occurrence of schizophrenia. Here we shall concentrate on how far the labor market influences the course and outcome of the illness.

Unemployment may exert an indirect influence on some people suffering from psychosis in the community. One stress factor known to be associated with poor outcome in schizophrenia is the effect of living with hostile, critical or emotionally over-involved relatives. The greater the proportion of time a person with schizophrenia spends in the company of such a relative, the greater is his or her chance of relapse.10 _{During an economic depression, both the relative and the}

patient are more likely to be unemployed and at home together. For the minority of people with schizophrenia who live with such a relative, this may be a serious stress. A successful treatment program that has been developed to reduce the high risk of relapse for such patients uses as one of its techniques efforts to increase the separation of patient and relative by getting one of them out of the house and at work.11

On the other hand, the home environment for the unemployed patient may be too under-stimulating. It was found in one five-year follow-up study of people with schizophrenia in London that for patients who were unemployed and living at home, the length of time spent doing absolutely nothing was similar to that of patients in backward asylums.12 _{Such poverty of daily existence is known to be}

closely allied to the clinical poverty of institutionalism and the negative features of schizophrenia.13

To emphasize, thus, the stresses of unemployment for people with schizophrenia is not to overlook the fact that, for many of these individuals, the stress of employment is also a major difficulty. People with schizophrenia experience severe problems, argues psychiatrist Hans Huessy, as a consequence of the “fabulously highly developed division of labor in industrial society.”14 _Work-

related stress is certainly important for these patients. In one group of people with schizophrenia, for example, 60 per cent had experienced a stressful life event in the three weeks before their psychotic breakdown; of these, the stress for one- third had been related to stopping or starting work, completing job training or changing hours of employment.15 _{Starting work, however, is an acute stress that,}

if weathered, may lead the person with psychosis to higher functioning. Unemployment, on the other hand, brings the chronic strain of low status and purposelessness, which may prevent recovery. Whichever part of the picture we study, nevertheless, it seems likely that the labor market is closely involved in the social production and perpetuation of psychosis.