The first edition of Recovery of Schizophrenia was acclaimed on publication as a work of major importance. It demonstrated convincingly, but controversially, how political, economic and labour market forces shape social responses to the mentally ill, mould psychiatric treatment philosophy, and influence the onset and course of one of the most common forms of mental illness. In this revised and fully updated edition, Dr Warner examines the changes in approach to schizophrenia since publication of his original book and analyses new research to answer the question: `Are they advances or not?'

Back to table of contents Previous article Next article Book ForumFull AccessRecovery in Mental Health: Reshaping Scientific and Clinical ResponsibilitiesRichard Warner, M.B., D.P.M.Richard WarnerSearch for more papers by this author, M.B., D.P.M.Published Online:1 Apr 2010https://doi.org/10.1176/appi.ajp.2009.09101397AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail by AmeringMichaela and SchmolkeMargit, translated by StastnyPeter. Chichester, U.K.Wiley-Blackwell, 2009, 280pp., $100.00. This is a rich and stimulating book that covers a broader field than we would ordinarily consider the "recovery" concept to encompass. There are sections dealing with health promotion, resilience, the effects of stigma, and the involvement of consumers of psychiatric services in the design and conduct of mental health research. There are a number of definitions of the recovery concept, but the following example, in which the authors summarize Davidson and colleagues (1), is particularly illuminating: "Recovery does not necessarily imply an improvement or elimination of symptoms and deficit, but rather relates to a learning process that enables people to live with long-term limitations and teaches them how to cope or compensate for them and to participate in community life as actively and satisfactorily as possible" (p. 45).The authors, a psychiatrist and a psychotherapist, reveal their enthusiasm for the topic of consumer-oriented services throughout the book (and in the postscript, they describe what drew them to the subject). They present a wealth of information from around the world, referenced with care. The book, originally in German, has been beautifully translated and updated for the English-language edition. As we read about consumer-developed recovery programs from the United States, Australia, and several European countries, recovery-oriented treatment systems from Scotland to Ohio, and the global involvement of the World Psychiatric Association, it becomes apparent that the recovery concept has had a significant impact on service delivery in a large number of developed countries, often with government support. America's earlier consumer-driven reform movement, the Mental Hygiene Movement of the early 20th century, did not have this broad an impact. This is something we cannot afford to ignore, particularly since, as with the Mental Hygiene Movement, the stimulus for the recovery concept has been the perception of widespread deficits in the adequacy of psychiatric care.The authors are not biased reporters, and they deal with each issue with balance and thoughtfulness. They are appropriately cautious about recent attempts to prevent psychosis through early intervention. Issues such as consumer empowerment and involuntary treatment are handled with delicacy from the perspective of both the patient and the clinician. Nor do the authors recommend, as some mental health policy makers have done, that we rely on subjective reports of quality of life or related measures in designing treatment programs, pointing out that subjective and objective data of this type are often at wide variance with one another. They do endorse, however, the expanded use of qualitative research and suggest, somewhat caustically, that psychiatry's emphasis on evidence-based research might be better regarded by consumers and family members if the results of, say, rehabilitation intervention research were more widely adopted in practice.Although the recovery concept has diffused as a social movement and hence will not necessarily be based on scientific evidence, this book offers ample research data on the central components of the model. We are shown the evidence for the substantial recovery rate from schizophrenia, and we recognize the reason for the optimism that is fundamental to the approach. One of the most robust findings in schizophrenia research since the time of Eugen Bleuler is that a significant proportion of those with the illness will recover completely and many more will regain good social functioning. We learn about the merits of consumer empowerment in improving outcomes from serious mental illness and how we can help it happen. We discover how consumer involvement in treatment benefits both the peer-provider and the recipient. A growing body of research supports the concept that empowerment is an important component of the recovery process and that consumer-driven services and a focus on reducing internalized stigma are valuable in empowering the person with schizophrenia and improving outcomes from the illness.As practitioners, what should we take from this book? The authors would want us to offer hope rather than unfairly negative prognoses. They would encourage us to eschew paternalism and to partner with our patients in making treatment decisions, offering them choices as a route to empowerment. They would expect us not only to treat our patients with dignity and respect but to insist that our coworkers do so, whatever the setting. And they would want us to bear in mind that psychiatrists have been criticized by a distinguished leader in the field as being sources of "iatrogenic stigma" of mental illness for ignoring some of these very precepts (2).Boulder, Colo.The author reports no financial relationships with commercial interests.References1 Davidson LHarding CSpaniol L(eds): Recovery From Mental Illness: Research Evidence and Implications for Practice. Boston, Boston University, Center for Psychiatric Rehabilitation, 2005 Google Scholar2 Sartorius N : Iatrogenic stigma of mental illness. Br Med J 2002; 324:1470–1471 Crossref, Medline, Google Scholar FiguresReferencesCited byDetailsCited byNone Volume 167Issue 4 April 2010Pages 478-479 Metrics PDF download History Accepted 1 October 2009 Published online 1 April 2010 Published in print 1 April 2010

The first edition of Recovery of Schizophrenia was acclaimed on publication as a work of major importance. It demonstrated convincingly, but controversially, how political, economic and labour market forces shape social responses to the mentally ill, mould psychiatric treatment philosophy, and influence the onset and course of one of the most common forms of mental illness. In this revised and fully updated edition, Dr Warner examines the changes in approach to schizophrenia since publication of his original book and analyses new research to answer the question: `Are they advances or not?'

Soixante-neuf personnes ayant des troubles mentaux, traitées dans le cadre d'un système rigoureux de soutien communautaire à Boulder au Colorado, ont été évaluées à l'aide des mêmes mesures de psychopathologie et de qualité de vie que celles utilisées pour l'évaluation de personnes similaires traitées dans des services hospitaliers et communautaires à Manchester, en Angleterre. La psychopathologie était plus grande dans l'échantillon de Boulder. Toutefois, sur le plan de la qualité de vie, les résultats des patients étatsuniens n'étaient pas moins bons que ceux des patients anglais. Nous examinons ici la relation entre ces conclusions, les systèmes de soins et la disponibilité des lits dans les hôpitaux psychiatriques.

Back to table of contents Previous article Next article Book ForumFull AccessRecovery Beyond PsychiatryRICHARD WARNER M.B., D.P.M.,RICHARD WARNER M.B., D.P.M.Search for more papers by this author,Published Online:1 Sep 2006https://doi.org/10.1176/ajp.2006.163.9.1651AboutSectionsView articlePDFView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail View articleIt is not clear for whom this book is written, but it may be valuable for people with serious mental illness and their family members who are struggling to determine the place of mainstream psychiatry in their lives.Dr. Whitwell is a British psychiatrist who has worked a lifetime in acute psychiatry and has re-evaluated his work in light of the recent influence of the recovery movement. In a sort of epiphany, Dr. Whitwell advances the theory that the keys to recovery lie not in traditional psychiatric treatment but in the individual’s own efforts and in his or her environment. Psychiatry is relegated, in his present vision, to a role in providing safety and support in urgent and dangerous situations. A consequence of this view is his opposition to involuntary outpatient psychiatric treatment. This is a personal account and a staunchly nonacademic book. The author rejects evidence-based medicine in favor of “clinical judgment.” There are few references and no index. Unfortunately the nonacademic nature of Dr. Whitwell’s work lays him open to accusations of provincialism. Little is included in the book if it has not impinged directly on the author’s practice. Consequently, there is no mention of any of the models which, in recent decades, have expanded the possibility of recovery for people with mental illness. We find no mention of American models such as the psychosocial clubhouse or supported employment, which have done much to enhance consumer empowerment, competitive employment, and social inclusion, or of European models such as social firms—businesses with a social mission to employ people with psychiatric and other disabilities—that have become a powerful rehabilitation force in many countries around the world. The author pays scant attention to the treatment innovations (originally British) of cognitive-behavioral therapy for psychotic symptoms and family psychosocial intervention, both of which are included in the updated treatment recommendations promulgated by the Schizophrenia Patient Outcomes Research Team (1) . The neglect of such valuable approaches leaves the reader more pessimistic than he or she needs to be about the contributions of modern mental health approaches to the possibility of the recovery of good functioning, quality of life, and meaning in life for people with serious mental illness. Dr. Whitwell does pick up on a European development about which he is enthusiastic—the Hearing Voices Network, developed by the Dutch psychiatrist, Marius Romme—referring to it as “a major social breakthrough.” He is right to emphasize the importance of this pan-European movement that connects people with mental illness with the much larger group of people with no mental disorder who regularly hear voices. The movement provides a normalizing and socially inclusive opportunity to discuss the phenomenon and meaning of auditory hallucinations, something which is of immediate concern to many people with serious mental illness. As Dr. Whitwell comments, the hearing voices work “returns autonomy to the individuals” and allows them to develop “an understanding of their voices that ...[is]...more helpful than the usual neuro-psychiatric explanation” (p. 71). American patients will be well served if this movement expands into North America as vigorously as it has diffused in Europe.The author makes a useful contribution in questioning the “doctor knows best” paternalism that discourages patients from taking charge of their illnesses, but he misses the opportunity in this book to foster the optimism that is a fundamental element of the recovery movement.Boulder, Colo.Reference1. Lehman, AF, Kreyenbuhl, J, Buchanan, RW et al: The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2003. Schizophr Bull 2004; 30:193-217Google Scholar FiguresReferencesCited byDetailsCited ByNone Volume 163Issue 9 September, 2006Pages 1651-1651THE AMERICAN JOURNAL OF PSYCHIATRY August 2006 Volume 163 Number 9 Metrics PDF download History Published online 1 September 2006 Published in print 1 September 2006

Bentall & Morrison (2002) point out one of the hazards of trying to prevent the onset of psychosis – that prescribing antipsychotic drugs to people who do not yet have the illness exposes those who have been inaccurately predicted to develop the illness to unnecessary risks. Their enthusiasm for using cognitive therapy for the prevention of psychosis, however, leads the authors into accepting two false assumptions of the prevention field, namely: . early intervention improves outcome in psychosis, and . predictive instruments are sufficiently accurate to justify intervention. I will explain why I believe these assumptions to be incorrect.

BackgroundBoth subjective and objective information is necessary to assess quality of life (QOL).AimsTo explore the role of subjective and objective QOL dimensions and their cross-sectional and longitudinal predictors.MethodThe relationship between QOL, as measured by the Lancashire Quality of Life Profile (LQL), and demographic variables, diagnosis, psychopathology, disability, functioning, affect balance, self-esteem, service use and service satisfaction was investigated at two points in time, using factor analysis and multiple regression techniques.ResultsOne subjective and two objective LQL factors with strong face validity were identified. Cross-sectional predictors of the subjective factor were primarily subjective measures; longitudinally, few predictors of this factor were identified. The cross-sectional and longitudinal predictors of the objective factors were primarily demographic and observer-rated measures.ConclusionsSubjective and objective data are distinct types of information. Objective measures may be more suitable in detecting treatment effects. Subjective information is necessary to complete the QOL picture and to enhance the interpretation of objective data.

Obstetric complications appear to increase the risk of developing schizophrenia, and post-World War II improvements in obstetric care may have contributed to a decline in the incidence of the illness in the developed world. Educating providers and consumers of psychiatric and obstetric services about the risk of obstetric complications in increasing the risk of schizophrenia could bring about a further small decrease in the incidence of the illness, safely and at low cost. On the other hand, attempts to prevent the occurrence of schizophrenia by treating people who manifest highrisk indicators prior to the development of the illness have a low probability of success and a high probability of unintended negative consequences. Early intervention with people who have developed the full schizophrenia syndrome is likely to have few negative effects and may yield benefits, although it is not yet clear that it will.

Work helps shape the social role of people with mental illness and may have positive effects on outcome. Employment rates for the mentally ill may be influenced by the general availability of employment, the provision of vocational rehabilitation services and by work disincentives in the disability pension system. In the recent tight labor market of Boulder County, Colorado, the rate of employment of people with psychotic illness has increased to around half of the population. A crucial factor affecting work disincentives appears to be the size of the 'earnings disregard', the amount of earned income which a disabled worker may receive before his/her governmental benefits are reduced or discontinued. Expanding the earnings disregard may help increase employment, decrease poverty and improve outcome for people with psychotic illness.

A group of clubhouse users matched with similar patients (not clubhouse users) in a neighbouring area were compared in terms of quality of life (Lancashire Quality of Life Profile), service utilization and treatment costs over a two year period.The clubhouse group achieved a reasonable employment status and good social relationships, and advantages in subjective well-being favoured the clubhouse group. Over two years the pattern of service utilization and costs also favoured the clubhouse group. When the two groups were disaggregated for employment status the group with least treatment utilization and lowest costs was the employed clubhouse group.

The aim of the study was to compare the quality of life (QOL) and needs of people with schizophrenia in comprehensive treatment systems in two countries. One hundred people with schizophrenia and schizoaffective disorder were randomly selected from the caseload of a community mental health center in Boulder, Colorado, and 70 were similarly selected from public psychiatric treatment services in and around Bologna, Italy. Subjects were interviewed with QOL and needs assessment instruments and rated with the Brief Psychiatric Rating Scale. Objective QOL measures favored Bologna subjects over Boulder subjects, particularly with respect to employment, accommodation, and family life. In a factor analysis, objective QOL variables sorted separately from subjective satisfaction ratings, suggesting that they measure different underlying constructs. Patient needs in both Boulder and Bologna samples were primarily psychological and social rather than basic survival issues. Boulder subjects were more likely to report accommodation needs. Many apparent QOL advantages for Bologna subjects could be attributed to the greater frequency with which the Italian patients lived with family of origin. Living with family also appeared to confer practical benefits in meeting needs. Objective QOL measures discriminated between patient populations better than subjective ratings of satisfaction and well-being.

OBJECTIVE:To investigate the effect of a capitated funding mechanism for the psychiatric care of Medicaid recipients, a study of outcome, satisfaction, and service utilization among adults with schizophrenia and schizoaffective disorder was conducted at a Colorado agency before and after the introduction of the new funding mechanism.METHODS:Two random samples of 100 clients each were selected, one a year before capitation was introduced and one a year after. Subjects were interviewed about their quality of life, needs, and service satisfaction. Psychopathology and service utilization were also measured.RESULTS:Psychopathology was lower after capitation in most dimensions. The number of subjects admitted to the hospital during a six-month period beginning a year after capitation was 57 percent lower than in the equivalent period before capitation, with no increase in the amount of outpatient treatment provided. Subjects reported improved quality of life in the domains of work, finances, and social relations. Significant changes in needs or service satisfaction were not detected.CONCLUSIONS:No evidence was found that Medicaid capitation had an adverse effect on the client population after one year. Findings suggested that capitation led to an efficient use of treatment resources.

Consumer cooperatives have been shown to be feasible in Europe for generating adequately reimbursed jobs for the mentally ill, and may be viable in the U.S.. Such businesses can gain a market advantage by offering goods and services to mental health agencies or to the consumer group. Interviews with 50 mentally ill people living in Boulder, Colorado, identified sizable markets controlled by consumers: the average mentally ill person in the sample consumes $2,000 a month in psychiatric treatment, accommodation, food, medication and other goods and services. The findings suggest several income-generating opportunities. Consumers can be employed as mental health service providers, under certain conditions a consumer-cooperative pharmacy may be established, and some types of housing cooperative are viable.