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Social Inclusion of People with Mental IllnessReview - Social Inclusion of People with Mental Illness
by Julian Leff and Richard Warner
Cambridge University Press, 2006
Review by Tony O'Brien, RN, MPhil.
Oct 24th 2006 (Volume 10, Issue 43)

This book is a collaboration between two professors of psychiatry, one in the UK, the other in the US, so it provides the opportunity to explore issues in community care for people with mental illness from two perspectives. As the book shows, there are differences in the way community care has developed in each country, and there is much to learn from the resulting experience. Julian Leff has been a consultant to WHO and has published extensively on issues such as expressed emotion and outcomes of community care for people with schizophrenia. Richard Warner has worked in mental health service in Boulder. Colorado, an area considered to have introduced many innovative interventions in community mental health care. His Recovery from Schizophrenia: Psychiatry and Political Economy (1994) has recently been reissued, and he has collaborated with Paul Polak to develop a model of economic development for consumers of mental health services.

The book is divided into two main sections, the first on one of the major causes of social exclusion, stigma, and the second on one of the solutions, employment. Issues are addressed through discussion of concepts, and a review of related research. As in many areas of mental health care, there is limited good quality research, which means that on occasion the authors fall back on persuasive arguments in advocating various interventions. However they have gathered together an impressive range of evidence that should encourage funders and policy makers that the approach they advocate, social inclusion, makes both social and economic sense.

A theme that is apparent in several chapters is the comparatively better outcome for schizophrenia shown in developing countries, especially in rural settings. This relates to both main themes of the stigma and employment, although the reasons for differences in outcome are not fully understood. Compounding the distinction between developed and developing countries is the effect of social class: in developed countries working class people experience inferior outcomes to upper social classes, no doubt related in part to their disadvantage in the labor market. Interestingly, this latter observation confirms a finding of public health research, that over decades of public health intervention one outcome that has changed little is the relative disadvantage in health outcomes between social classes.

The issues of stigma, discrimination, work, and income are illustrated by pithy vignettes scattered throughout the text. These are first person accounts of an issue under discussion and serve to remind the reader that the issues debated by clinicians, researchers and policy makers are played out in the lives of real people. They keep the book focused on the issue at hand: people with mental illness, and their experience of health and social care.

The first section explores stigma, poverty and mental illness, with a particular focus on showing how mental illness requires a social model of understanding, not simply a traditional medical model aimed at symptom management, however important that might be at some points. The authors plead for greater public tolerance, willingness to question stereotypes and, importantly from the perspective of health professionals, the need to examine how professionals' stereotypes can contribute to stigma and exclusion.

The period of deinstitutionalization is shown to have unfolded differently on either side of the Atlantic, and to have heralded an unforeseen range of problems. This is a recurring theme in mental health literature, and this book reminds us how, against a background of institutional care, issues such as social inclusion looked rather more clear cut than they proved to be in the postinstitutional era. I have heard it remarked that consumer advocates of the 1970s have achieved everything they demanded: closure of the institutions, involvement in the governance of mental health services, influence at the highest political levels, yet still the call is for change. That anecdotal remark illustrates how much the social landscape has changed in the past three decades. Social Inclusion of People with Mental Illness indicates that there is more change afoot, as the aim focus for people with mental illness shifts to full citizenship rather than simply good mental health services.

In the section on barriers to employment Leff and Warner attempt to give empirical support and practical weight to advocacy that would otherwise be rights-based, and perhaps more likely to be resisted. By marshalling evidence on the impact of employment on clinical outcomes in schizophrenia, and by examining the effect of adjusting allowable income for beneficiaries, the authors are able to argue that what seems like the right thing to do for reasons of social ethics, also makes sense in terms of improved clinical outcomes and quality of life. The evidence is by no means definitive, but it does suggest that the argued benefits of social inclusion can actually occur when health and social policy are aligned. The authors review a range of employment programs, showing through this analysis the need to tailor programs to the needs of individuals, especially needs related to mental illness. For some this might mean retention of a revised form of the out-of-favor "sheltered workshop" model; for others it may be supported employment with a view to eventual participation in the competitive economy. The Italian "social firm" model of employment pioneered by Basgalia in Trieste is discussed in some detail in a separate chapter, which also traces its dissemination to other countries.

The chapter on innovative strategies begins by referring to what is an implicit commitment of the book, that "social inclusion" should lead to "full citizenship" for people with mental illness. There may be some readers who will feel frustrated that this philosophical position is not explored in some depth, but this is a brief book with a practical orientation. The intent seems to be to focus on what works, rather than explore the underlying theory. Of course there are potential pitfalls in such pragmatism, but if the book is taken in the context of the authors' larger body of work (especially Warner's Recovery from Schizophrenia) then there is ample explication of the theory behind the current work. A feature of the innovative strategies is the employment of consumers in providing both clinical and business services. Thus employment strategies converege with a frequently stated objective of the recovery movement, that clinical services can and should be provided, at least in part, by consumers of those services. Warner and Leff describe consumer run clinical services, clinical support services, housing ownership enterprises and business schemes. They discuss the potential ethical issues involved for both professionals and consumers in terms of issues such as boundaries and privacy.

The final chapter of the book covers consumer advocacy, with a section a the end on the recovery movement. Interestingly this section signals a possible rapprochement between advocates of the consumer focused recovery model with its emphasis on consumer empowerment, with more traditional psychiatrists who advocate evidence-based care. It will be interesting to see how that development unfolds. I felt that perhaps "recovery" was included a little late in the book, especially given the development of a recovery discourse which has a very different notion of recovery to the more traditional model of recovery that informs this book.

It is significant in terms of the current state of international psychiatry that medically trained consultant psychiatrists, steeped as they are in the traditions of their discipline, find it necessary to look to social explanations and interventions to problems of mental illness rather than biological theories. While much of psychiatry looks towards the promise of neurobiology, Leff and Warner look outwards, at the social conditions that shape mental illness, and the sorts of conditions that might make for a better life for the mentally ill. They do this without abandoning their commitment to medicine or psychiatry, and without aligning themselves with politicized movements based on challenging existing models of care. Social change, however, is what this book is about.

Social Inclusion of People with Mental Illness appears to be pitched at practitioners new to mental health, or perhaps looking for a plainly written overview to what used to be called "social psychiatry". If that is the case the book succeeds admirably. Much of the material has been extensively reported in various journal publications over almost two decades, and the book provides plenty of references for those who wish to pursue the original research and publications. It will be useful for mental health professionals, consumers, researchers and policy makers. For anyone wanting an introduction to the evolution of postinstitutional approaches to mental health care, and social interventions aimed at increasing inclusion this book is a great start.


2006 Tony O'Brien


Tony O'Brien, RN, MPhil. Senior Lecturer, Mental Health Nursing, University of Auckland,


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