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Social Inclusion of People With Mental Illness
Reviewed by DAVID CUTLER
Am J Psychiatry 2007;164:982-983.
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by Julian Leff and Richard Warner. New York, Cambridge University Press, 2006, 202 pp., $55.00.

Integration into everyday life in ordinary communities for persons suffering with long-term mental illness has continued to seem as difficult as unraveling the Gordian knot, despite enormous efforts to create community-based mental health systems throughout the industrialized world. Even though large state hospitals have been closed in Italy and downsized in the United Kingdom and the United States, individuals with long-term mental illness continue to suffer because of a lack of accessible and meaningful work opportunities in the community, and they continue to face significant basic survival barriers due to financial difficulties and stigma. In recent years, there has been a large volume of new literature on supported employment and housing in the community, but not much attention is paid to the overwhelming barriers confronting persons with mental disorders who have little energy available for problem solving on their own, due to the effects of their illnesses. In their new book, Julian Leff and Richard Warner face head on the deleterious effects of social discrimination and stigma, which prevent opportunities from emerging for these unfortunate individuals.

In Part One, Dr. Leff covers the origins of this stigma in all of its various forms, including poverty, institutionalization, and public fear and discrimination. He connects the course and features of severe mental disorders with the community’s discriminatory practices and social disadvantages encountered by unemployed former hospital patients. The old institutions were at least able to provide an available home and activity center for such individuals. The closing of hospitals in the United States, Italy, and Britain left many with no place to call home. I personally remember 25 years ago when I spent several months in England on sabbatical, I asked a patient in a long-stay hospital there why she seemed so satisfied with the chilly, tatty, rundown hospital ward with no privacy she was stuck in. Her reply was, “The Queen has her castles, and I have mine.” Unfortunately for this apparently happy woman, those cold, old psychiatric “castles” began to close shortly after our conversation.

In Part 2, Dr. Warner presents his theories on various ways to overcome obstacles to employment for discharged patients, beginning with a rationale for work and its effects on self-esteem and uncovering some connections between unemployment rates and vocational services. He shows us how low unemployment rates are associated with more social recovery, and the opposite is true during periods of economic recession. He also reviews the literature on transitional and supported employment and provides us with a manual on how to set up work cooperatives run by consumers for consumers. He reminds us of the movement in recent times to hire consumers in the mental health work force as case manager aides, as therapists, as community educators, etc. He informs us about innovative schemes such as consumer run housing, businesses, and pharmacies that keep the cost of drugs down. The final chapter on inclusion and empowerment shows us how the consumer movement itself, along with consumer operated drop-in centers and clubhouses, provides individuals with long-term mental illness that missing sense of community that used to exist in the old asylums and creates a certain human substrate that leads ultimately to recovery.

I would recommend this little book to academic training programs in psychiatry, community psychiatry, and social work for those seeking the bright side of work with persons with serious mental illness, as well as community mental health authorities and programs looking for the best in current practice for integrating mentally ill persons back into their communities.




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