New myths and harsh realities: Reply to Paul on the Implications of Paul and Lentz (1977) for Generalization From Token Economies to Uncontrolled Environments (original) (raw)
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Behavior and Social Issues, 2006
Wyatt, Midkiff and Wong argue that biological psychiatry's power, not its scientific merits, explain token economies' eclipse by biological treatments of schizophrenia. However, these critiques of biological psychiatry, while partly true, ignore offsetting strengths and achievements as well as plausibility arguments that schizophrenia is partly biological; behavioral theory offers no cogent alternative account of etiology. Moreover, token-economy research failed to establish generalizability of changes to post-ward environments. Even Paul and Lentz's (1977) definitive research on token-economy treatment of schizophrenia failed to show generalization of changes to community life, and in fact, due to an inadvertent "natural experiment," revealed the instability of behavioral changes even after years of treatment. To preserve their belief system, behaviorists seem in danger of turning behaviorism into a pseudoscience defended by ad hoc hypotheses.
Rethinking social recovery in schizophrenia: What a capabilities approach might offer
Social Science & Medicine, 2007
Resurgent hopes for recovery from schizophrenia in the late 1980s had less to do with fresh empirical evidence than with focused political agitation. Recovery's promise was transformative: reworking traditional power relationships, conferring distinctive expertise on service users, rewriting the mandate of public mental health systems. Its institutional imprint is considerably weaker. This article takes sympathetic measure of that outcome and provides an alternative framework for what recovery might mean, one drawn from disability studies and Sen's capabilities approach. By re-enfranchising agency, redressing material and symbolic disadvantage, raising the bar on fundamental entitlements and claiming institutional support for complex competencies, a capabilities approach could convert flaccid doctrine into useful guidelines and tools for public mental health. Keywords recovery; schizophrenia; capabilities; disability; public mental health; USA Ambiguity about core values, operational principles, and organizational goals has its strategic uses, among them the formation of unlikely coalitions in pursuit of structural change. Such amalgams have figured critically in the annals of mental health reform, though the roles of specific groups or external constraints remain disputed and the verdict of history mixed (compare Scull, 1976, with Grob, 1991). Institutional reform inevitably involves a reckoning, a sorting out of competing versions of allegedly shared assumptions, and their selective translation into practice and policy. "Working misunderstandings" can carry a merry band of reformers only so far before political realities step in to call the question and tally the bill. This article takes stock of the institutional imprint of "recovery" from severe psychiatric disability in U.S. public mental health, and does so from an applied anthropological stance. This may surprise some. Anthropologists are best known for bringing a spoiler's sensibility to their reading of psychiatric procedure, dusting for cultural fingerprints on the suspect premises of clinical practice-like discerning traces of "governmentality" where others see therapy or empowerment (Rose, 1999; Joseph, 2002). A second, lesser-known tradition claims the same ancestry but applies a rather different sensibility. Its proponents (initially Estroff, 1981) tend to portray contemporary community psychiatry as unusually hard repair work in socially suspect precincts (Rhodes,
The Psychosocial Treatment of Schizophrenia: An Update
American Journal of Psychiatry, 2001
The authors sought to update the randomized controlled trial literature of psychosocial treatments for schizophrenia. Method: Computerized literature searches were conducted to identify randomized controlled trials of various psychosocial interventions, with emphasis on studies published since a previous review of psychosocial treatments for schizophrenia in 1996. Results: Family therapy and assertive community treatment have clear effects on the prevention of psychotic relapse and rehospitalization. However, these treatments have no consistent effects on other outcome measures (e.g., pervasive positive and negative symptoms, overall social functioning, and ability to obtain competitive employment). Social skills training improves social skills but has no clear effects on relapse prevention, psychopathology, or employment status. Supportive employment programs that use the place-and-train vocational model have important effects on obtaining competitive employment. Some studies have shown improvements in delusions and hallucinations following cognitive behavior therapy. Preliminary research indicates that personal therapy may improve social functioning. Conclusions: Relatively simple, long-term psychoeducational family therapy should be available to the majority of persons suffering from schizophrenia. Assertive community training programs ought to be offered to patients with frequent relapses and hospitalizations, especially if they have limited family support. Patients with schizophrenia can clearly improve their social competence with social skills training, which may translate into a more adaptive functioning in the community. For patients interested in working, rapid placement with ongoing support offers the best opportunity for maintaining a regular job in the community. Cognitive behavior therapy may benefit the large number of patients who continue to experience disabling psychotic symptoms despite optimal pharmacological treatment.