Social Aspects of Schizophrenia Care

“Truly I say to you, to the extent that you did it to one of these brothers of Mine, even the least of them, you did it to Me.”

—Matthew 25:40 (New American Standard Bible)

A useful distinction can be made between the sociology in psychiatry and the sociology of psychiatry. The sociology in psychiatry concerns itself with the impact (either causative or modifying) of social factors on disease (e.g., the role of anomie in suicide, the role of immigration on schizophrenia risk, the role of family stress on relapse risk, the effects of class and race on health). The sociology of psychiatry examines psychiatry’s role in societies, particularly with regard to social control of “deviance” (e.g., the effects of getting a stigmatizing disease label; the parameters for involuntary treatment; the function of the state hospital as a “total institution,” a term coined by Erving Goffman). Many sociologic aspects of care are discussed throughout this book. In this chapter, I focus on social adversity, stigma, and the current health care system.

SOCIAL ADVERSITY

It is impossible to practice medicine without acknowledging the social realities of patients. Paul Farmer, an infectious disease specialist who has spent most of his career traveling between Harvard and Haiti to bring modern medicine to rural Haiti, has stressed the importance of biosocial causation of illnesses. It is not possible to isolate an illness and study its “natural course” without considering how people ended up in harm’s way, their access to care, and their adherence to treatment. Farmer uses the term “structural violence” (a term coined by Johan Galtung and by liberation theologians in the 1960s to denote social structures that impede humans from reaching their potential) to emphasize the pernicious effects of adverse social conditions on clinical outcomes. The “natural” history of tuberculosis varies greatly, depending on where and how you contract the bacterium and what kind of treatment you get. Similarly, the “natural” history of schizophrenia will be difficult to understand if social factors are ignored.

The social consequences of schizophrenia are rather significant. Having schizophrenia puts you at an economic disadvantage, and many patients experience a downward social drift into unemployment and poverty (social selection theory). A significant minority of the homeless population has schizophrenia, perhaps as many as 15% to 30%, probably for the most part due to lack of affordable housing.

STIGMA

It is a myth that “schizophrenia is an illness like any other.” If it were, patients would not have to decide whom they are going to tell about it. Schizophrenia is a highly stigmatizing condition; being afflicted with it leaves the sufferer with a “mark or token of infamy, disgrace or reproach.” Stigma is a powerful psychologic force and a societal reality for patients with mental disorders, including schizophrenia. The pervasive emotion attached to stigma is shame, leading patients to deny illness, hide symptoms from others, and refuse to seek care. Shame can be pervasive in families themselves; you can see this in families in which a positive family history of psychotic illness might never be acknowledged.