by Richard Warner
Review by Christian Perring on Jul 14th 2008
One of the major empirical and conceptual controversies for the whole history of psychiatry concerns the possibility of recovery from schizophrenia. Kraepelin was one of the main theorists to posit the disorder as a discrete entity, and in naming it dementia praecox (premature dementia) he expressed his judgment that it is a permanent condition. Since the end of the nineteenth century, there have been related debates about how best to define schizophrenia and whether it is possible to recover from it partially or completely. In 12-Step Plans, people talk about being "in recovery" but also describe addiction as a life long condition, so the notion of recovery itself has shown flexibility, since it used to be that recovery from a disease meant that it was gone. In recent years, ideas of the recovery movement have spread to rehabilitation, and even people with serious mental illnesses will describe themselves as being in recovery.
Richard Warner places himself firmly in the camp supporting the idea of recovery from schizophrenia in his book Recovery from Schizophrenia; the notion of recovery is basically sufficient reduction of symptoms for a person to be able to return to the workforce, although he does not define the term narrowly in this way. His main contention is that changing economic conditions and especially doing productive work can improve the recovery rate for people with schizophrenia. His book, first published in 1985, is now in its third edition. It is a comprehensive survey of the theories about schizophrenia, the different treatments for the disorder now and in the past, approaches to treating schizophrenia in the Third World, the experience of living as a person with schizophrenia in the west, the importance of work for recovery, and ways to improve rehabilitation services. It is written very clearly, and each chapter has a summary of the main points at the end.
Warner accepts that schizophrenia is fundamentally a biological condition, but as with many other biological conditions, the course of the disorder is fundamentally affected by the economic conditions. When jobs are easier to find, more people recover from schizophrenia, and when jobs are harder to find, recovery rates decline. Even when it is possible to produce correlations, it is hard to prove causation, but Warner makes a strong case that these phenomena are at least intimately tied. He quotes many studies and literature reviews, sometimes at length, to make his case. He uses data from the USA, the UK and Ireland, and many other countries. Often he returns to the theme of the Tuke Retreat in the late 18th and early 19th centuries, which used "moral treatment'" this had many aspects, but especially important to Warner is that patients were put to work performing useful tasks, and the recovery rates were impressive. Warner accepts that medication is often a very helpful treatment, but he points out that it may not always be the best treatment, and it should not be used as a substitute for other psychosocial approaches. He shows that despite our advances in treatment in the last century, recovery rates have not significantly improved. He also points out that there are many abuses of people with schizophrenia, and that stigma is a major factor in the problems for helping people with severe mental disorders. Warner draws on information from his home state of Colorado regarding the rehabilitation services there as a model for how to improve treatment outcomes.
The chapter on schizophrenia in the Third World is maybe the most philosophically interesting because it raises major questions of how to conceptualize mental illness in different cultures, or whether schizophrenia is a universal concept that can be applied equally in all cultures. Similar issues arise in applying the concept of schizophrenia to previous centuries, in rather less urgent form. Warner does not press these issues philosophically, and keeps the conceptual discussion to the minimum necessary for his main purposes. The chapter on the Third World attempts to cover a huge area in relatively few pages, and could easily be expanded to a book of its own. Nevertheless, philosophers and medical anthropologists will find his discussion here fascinating, and it could serve as a starting place for a sustained investigation of the cultural variation in the understanding of schizophrenia.
As a philosopher, I don't have the expertise in the wide range of empirical literature, from Western economic history, through non-Western medical anthropology, the history of psychiatry, modern clinical studies, to modern psychopharmacology and genetics to judge the adequacy of Warner's survey of the field or his interpretation. Indeed, one wonders how many people would be competent to assess the whole range of claims in the book. Nevertheless, it has stood up to the criticism of previous editions and is up to date with recent information. It is careful and nuanced, as well as reasonably thorough in its argument. For anyone who is interested in the debate over the best policy for treating schizophrenia, and the economic factors relevant to mental health treatment, Recovery from Schizophrenia is essential reading.
© 2008 Christian Perring
Christian Perring, Associate Professor of Philosophy, Dowling College, New York.