Social Therapies

In the USA in the 1960s, the era of the Civil Rights Movement, the rise of Feminism, and President Kennedy’s Community Care policy, psychoanalysis became a country-wide fad. Much of Woody Allen’s humor was based on poking fun at psychoanalysis. More significantly, a personal analysis was an essential requirement for a chairperson of a Department of Psychiatry. Over the next several decades the pendulum swung away from psychoanalysis towards biological explanations for psychiatric disorders, partly as a result of technological advances in brain imaging and genetics, but also due to the campaigning of the large and powerful pharmaceutical companies. Today psychoanalysis is almost extinct in the USA. The emphasis on an exclusively biological basis for schizophrenia generated a mind-set inimical to the notion of recovery.

There was never such a wholesale commitment to psychoanalysis in the UK, where the number of analysts has not exceeded several hundred for a population of 55 million. Furthermore the majority of analysts live in the major cities, and there is only a handful in the north of England. The dominant ideology in mental health has been a social approach, the pioneers of which were active from the 1930s, establishing community services before the advent of psychotropic medication. The founding of the National Health Service in 1948 provided a basis for social therapies such as rehabilitation, with an emphasis on recovery from psychiatric illnesses including schizophrenia. From the 1950s onwards, successive governments of both the Right and the Left supported a policy of deinstitutionalization, which has been effective in reducing the number of psychiatric hospitals in England and Wales (Scotland has its own Department of Health) from 130 to less than a dozen. The discharged long-stay patients are living in much improved conditions with greater freedom, and there has been almost no homelessness, or victimization.

The emphasis on a social approach in the UK has led to important advances in the non-pharmacological treatment of schizophrenia. These include professionals working co-operatively with family careers and patients, with a reduction in relapse for the most vulnerable patients from 50% over 9 months to 10 %. British psychologists have adapted cognitive behavior therapy, developed in the US for depression, for the treatment of schizophrenia, with a reduction in delusions and the distress due to auditory hallucinations. Recently a computer-assisted therapy has been developed for the treatment of auditory hallucinations resistant to medication, which has been effective in reducing the frequency, volume and malevolence of the voices in many patients. A minority even ceased to hear the voices altogether. These social therapies do not abolish the need for antipsychotic medication, but are free of side effects and produce improvements in the symptoms that enable patients to re-establish productive and satisfying lives.
Julian Leff