Holistic approaches

Richard Warner is a psychiatrist with a broad social view of mental illness who has made a significant contribution, particularly to the management of schizophrenia. Though British, he has worked in the United States for many years, mainly in the small city of Boulder, Colorado. Unlike others whose sociological position causes them to reject biological evidence and even deny the existence of schizophrenia, Warner accepts the contribution of every relevant discipline, except psychoanalysis. His first book, Recovery from Schizophrenia , had a Marxist feel and was somewhat starry-eyed about circumstances in the then-communist countries. This political strand has now been dropped, to the benefit of his argument.

Warner believes that environmental factors influence every aspect of schizophrenia and that if we were to make full use of existing knowledge, we could reduce its frequency and improve the quality of life of those affected. But long experience has taught him that mental-health professionals have a limited capability to influence those environmental forces that impinge on schizophrenia. He has therefore addressed this work primarily to mental-health service managers and policy-makers. It is free from technical jargon, while packing in a good deal of scientific information.

Acknowledging, as he does, the importance of genetic factors, which so far cannot be influenced, still leaves the opportunity to reduce primary environmental risks. In Warner's view, the most important of these are obstetric complications, recorded in up to 40 per cent of schizophrenia cases. It follows that better obstetric care should eventually lead to a reduced incidence of this psychosis. There are hints that this is already happening, though the evidence is not unequivocal.

Yet changing health services is an immensely complex business, and Warner's practical suggestions are to develop educational programmes on obstetric care and reducing stigma. He would also like to see a lower rate of smoking in pregnancy, though British research has shown that the women who most need this advice are most resistant to it.

His attitude to treatment is eclectic. The essential role of the anti-psychotic drugs is accepted, though he believes that if environmental stress is reduced their doses can often be reduced. But medication is just part of a package that, in his view, should also contain cognitive-behavioural therapy and family intervention.

Both these psychological procedures have suffered from the backlash against psychoanalytical dogmas that were highly influential in the US up to the mid-1970s. The most pernicious of these was to blame families for causing schizophrenia.

The value of calming family atmospheres was demonstrated in Britain more than 25 years ago. It continues a tradition of protecting sufferers from environmental stress that began at the York retreat in the 1790s. Cognitive-behavioural therapy also has a good evidence base. But neither is often used. Warner demonstrates how social security and tax systems operate against patients being able to take paid work, which would help morale and self-esteem.

His many examples from the Boulder mental-health service do raise the problem that this academic and high-tech community is unrepresentative of the US. Also, family intervention cannot be used for schizophrenics if there is no family contact, which is common in that country. Experts may also raise their eyebrows at the summary of biological knowledge. But this short and readable work should stimulate professionals of many kinds to help improve the care of people with schizophrenia.

Hugh Freeman is honorary visiting fellow at Green College, Oxford.