Our demand for efficiency will turn the hardest hit into outcasts
"Given that life can be improved for 50 per cent of the schizophrenia patients who are hardest hit, then of course it must be possible to substantially reduce the rate of relapse in the remaining, more mildly affected group and thereby improve the quality of their lives."
These words, based on his own experience, come from the Danish social psychiatrist Preben Brandt.
The hardest-hit group are a familiar sight in all large cities throughout the world. Some are known as "bag ladies" or "tramps", but there are others who are much less obvious.
They generally refuse to have contact with the authorities or those who can provide treatment. They experience delusions, deep anxiety and considerable suffering.
And even though there are exceptions, they are usually homeless - at least to the extent that they do not feel that they belong to the community in which they live. They have a miserable life, as social outcasts
What does society do for them? Preben Brandt: "Basically nothing. It's a group which is not mentioned in psychiatric textbooks and generally speaking we all hide behind the classical arguments for avoiding taking a view or becoming involved:
For a year he wandered through the streets of Copenhagen with a colleague and made contact with 35 homeless people suffering from schizophrenia - 18 men and 17 women between the ages of 22 and 70.
The visible results
After a year, the following results had been achieved. Of the 37, 19 had a clearly better life. Two felt worse and 16 either felt the same as before contact was made or had disappeared.
In other words, it was helpful. Even though, as Preben Brandt points out, these were people who had experienced one relapse after another - or whose entire lives were one long relapse.
"But although there is comprehensive literature about the treatment of the large groups of patients suffering from schizophrenia, there is very largely nothing that can be used either in discussion with homeless people suffering from schizophrenia or in their treatment," says Preben Brandt. "We were completely on our own.
You cannot close your eyes
"In the western world, it is the norm in psychiatric treatment for patients to take the initiative. So, obviously, whether or not it is reasonable to go out onto the streets and make contact with people with the aim of interfering in their lives is a fundamental question.
"Today I am in no doubt about the answer. It is reasonable. It
is quite simply impossible to close your eyes to the deep misery and isolation
of these people. So it is not only reasonable; in certain situations it
is our duty to become involved in other people's lives. In advance of
our project, we decided that we would not use compulsion. That was a decision
that we had to reverse. In 12 cases we committed homeless people suffering
and 11 of them experienced a marked improvement.
Preben Brandt has drawn three conclusions from the project:
1. Many of the homeless suffering from schizophrenia would, in reality, like to undergo treatment but are not immediately able to make the decision. The prerequisite is for a strong bond of trust to be created between patient and doctor and for long-term stable contact to be maintained. It is a process which requires great patience.
2. Medicinal therapy and admission to hospital are important elements in the treatment. Medicinal treatment is particularly beneficial for younger patients, for whom the chance of a return to the community is greatest, as well as for those patients who experience a high degree of suffering.
3. Many different groups must be involved in the work. Psychiatrists, hospitals, general practitioners and the entire social welfare system. And the best possible contact must be maintained with the patient.
A life in schizophrenic balance
"You can, of course, ask yourself if it is reasonable to use time and energy on actively trying to help a group of patients who represent a very small proportion of the total number of people suffering from schizophrenia," says Preben Brandt. "First, however, I am in no doubt that by working with the group with the biggest problems you learn a great deal about how the larger groups can be treated and about the relevant mechanisms in these people's lives.
"Secondly - and this is of decisive importance - it works. Many achieve a better life. For homeless people suffering from schizophrenia, the aim is not necessarily to achieve a life within a stable, normal framework, with regular work, a flat and leisure interests. A life in schizophrenic balance can also be a good life - one in which they establish relationships with other people and in which they gain access to various elementary necessities, such as food, a bath, a bed etc.
"We can create this life in schizophrenic balance for many of these patients if we become involved. If we treat them."
No country yet has precise figures of the number of people suffering from schizophrenia who are homeless, but Preben Brandt fears that the total is rising and that it is a general phenomenon in the western world.
"In all parts of our society we are becoming steadily more efficient. Psychiatry is no exception. Efficiency is measured in terms of the results achieved from treatment and, in this context, the homeless psychotic patients increasingly risk becoming victims of the rejection mechanisms that once and for all push them out of the treatment system. When they are out of the system, they are out of the statistics. They no longer exist - at least not until other people complain violently enough to the politicians about the disturbance and aggression caused by the homeless in public places."
Reprinted with permission.
Internet Mental Health (www.mentalhealth.com) copyright © 1995-2011 by Phillip W. Long, M.D.