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, a.obrien@auckland.ac.nz