SCHIZOPHRENIA: Institutionalism and Schizophrenia.

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SCHIZOPHRENIA Institutionalism and Schizophrenia. By J. K. WING and G. W. BROWN. Cambridge University Press. 1970. Pp. 260. Price J3.75. In their Maudsley Monograph †̃¿ Schizophrenia and Social Care' (1966) Brown, Wing and their colleagues reported an empirical evaluation of hospital and community care, as practised by three highly-regarded English hospital-based services, during the 196o's. They showed, among other things, that the rehabilitation of chronic schizo phrenic patients requires a sustained, active sequence of interventions, but that all too often there was a sudden falling-off of therapeutic involvement soon after the patient left hospital. This led, in many cases, to exacerbations of symptoms and episodes of crisis leading to re-admission. The authors, while demon strating current gaps in the services, concluded: †̃¿ The survey has convinced us that there are diffi culties in community care but not that the problems are insuperable.' Some attention was given in that monograph to the influence of social factors within the hospital, as well as in the community, upon the manifestations of the illness. The present work is focused upon the former setting. It consists of a systematic study of †̃¿ institutionalism' (or as Dr. Russell Barton termed it †̃¿ institutional neurosis') in groups of female schizo phrenic patients in the same three hospitals. As we have learned to expect of Professor Wing and Dr. Brown's work, the concepts associated with these terms are clearly stated, and reliable techniques of observation are worked out, in order to obtain measures, at different points over an eight-year period of the patients' clinical state on the one hand, and the degree of †̃¿ social mpoverishment' of their daily experience on the other. During the eight years, changes occurred in the social attributes of the patients' life in all three hospitals: where the patient's experience became †̃¿ socially enriched', there was a significant improvement in some of their manifest symptoms—a differential improvement, which could not be accounted for by their medication, or by their original clinical state. The concept of institutionalism has been widely accepted for many years. Already in :93o—long before the advent à f effective physical methods of treatment—Dr. Harry Stack Sullivan had demon strated that changes in the social environment of young schizophrenics led to an amelioration in their symptoms. Since then there have been numerous similar demonstrations, in which social changes of a wide variety—including †̃¿ total push', industrial therapy, and the permissive regime of Shenley Hospital's †̃¿ Ward 21†̃¿ —have b en followed by im provement in the patients' clinical condition. Because the apparently therapeutic social experiences were so varied, so complex, and so difficult to define with precision, the suggestion began to be made that perhaps what they had in common was a change in attitude on the part of the staff members who came into daily contact with the schizophrenic patients, conveying new expectations of improved behaviour, to which the patient responded. This type of placebo effect could well result in short term improvements, but could hardly be expected to continue to operate over a period of years. Reports of milieu therapy have begun to use systematic clinical evaluations to document changes in the patients' state, but they have seldom been able to specify in any detail the changes in their social experiences. The present study differs from these earlier demonstrations in the care taken to specify just what †̃¿ social impoverishment' and its converse †̃¿ social enrichment' means for the individual patient, in practical terms, such as whether the patients retained certain personal possessions, the frequency of their contacts with staff and of their changes of location during the day, their activities during their waking hours. This documentation has great practical importance, not only for all those doctors, nurses and occupational therapists engaged in the treatment of schizophrenic patients in hospital, but equally for their colleagues who will be concerned with their subsequent care. Only if the lessons spelled out here, about the inter action of medicinal and social therapy, are learned and applied during prolonged periods of discreet follow-up surveillance and help will our much vaunted slogan of †̃¿ communitycare' become an effective reality. G. M. CAR5rAms.