Today’s treatment picture for schizophrenia and other severe mental disorders is marked by miraculous triumphs for some, modest success for others, and heartbreaking failure for still others. It is typically characterized by medications, medication-linked health problems, compromised lifestyles, and a mixture of hope and frustration. Despite this, today’s treatment outlook is vastly superior to that of past years. In fact, for much of human history, people with such disorders were considered beyond help. Few returned to any semblance of normal or functional living. Indeed, few returned home from the institutions to which they were sent.

Let us look at the case of Cathy, whose journey is typical of that of hundreds of thousands of people with schizophrenia and other severe mental disorders. To be sure, there are other patients whose efforts to overcome schizophrenia go more smoothly. And at the other end of the spectrum, there are many whose struggles against severe mental dysfunctioning never come close to Cathy’s level of success. In between, there are the Cathys.

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As Cathy’s journey illustrates, schizophrenia is extremely difficult to treat, but clinicians are much more successful at doing so today than they were in the past. Much of the credit goes to antipsychotic drugs—imperfect, troubling, and even dangerous though they may be. These medications help many people with schizophrenia and other psychotic disorders to think clearly and to profit from psychotherapies that previously would have had little effect for them (Skelton et al., 2015; Miller et al., 2012).

To best convey the plight of people with schizophrenia, this chapter will depart from the usual format and discuss the treatments from a historical perspective. A look at how treatment has changed over the years will help us understand the nature, problems, and promise of today’s approaches. As we consider past treatments for schizophrenia, it is important to keep in mind that throughout much of the twentieth century the label “schizophrenia” was assigned to most people with psychosis. Clinical theorists now realize that many people with psychotic symptoms are instead experiencing a severe form of bipolar disorder or major depressive disorder and that such people were in past times inaccurately diagnosed with schizophrenia (Tondo et al., 2015; Lake, 2012). Thus, our discussions of past treatments for schizophrenia, particularly the failures of institutional care, are as applicable to those other severe mental disorders as they are to schizophrenia. Similarly, our discussions about current approaches to schizophrenia, such as the community mental health movement, often apply to other severe mental disorders as well.

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For more than half of the twentieth century, most people diagnosed with schizophrenia were institutionalized in a public mental hospital. Because patients with schizophrenia did not respond to traditional therapies, the primary goals of these hospitals were to restrain them and give them food, shelter, and clothing. Patients rarely saw therapists and generally were neglected. Many were abused. Oddly enough, this state of affairs unfolded in an atmosphere of good intentions.

As you read in Chapter 1, the move toward institutionalization in hospitals began in 1793 when French physician Philippe Pinel “unchained the insane” at La Bicêtre asylum and began the practice of “moral treatment.” For the first time in centuries, patients with severe disturbances were viewed as human beings who should be cared for with sympathy and kindness. As Pinel’s ideas spread throughout Europe and the United States, they led to the creation of large mental hospitals rather than asylums to care for those with severe mental disorders (Goshen, 1967).

These new mental hospitals, typically located in isolated areas where land and labor were cheap, were meant to protect patients from the stresses of daily life and offer them a healthful psychological environment in which they could work closely with therapists (Grob, 1966). States throughout the United States were even required by law to establish public mental institutions, state hospitals, for patients who could not afford private ones.

Eventually, however, the state hospital system encountered serious problems. Between 1845 and 1955, nearly 300 state hospitals opened in the United States, and the number of hospitalized patients on any given day rose from 2,000 in 1845 to nearly 600,000 in 1955. During this expansion, wards became overcrowded, admissions kept rising, and state funding was unable to keep up.

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The priorities of the public mental hospitals, and the quality of care they provided, changed over those 110 years. In the face of overcrowding and understaffing, the emphasis shifted from giving humanitarian care to keeping order. In a throwback to the asylum period, difficult patients were restrained, isolated, and punished; individual attention disappeared. Patients were transferred to back wards, or chronic wards, if they failed to improve quickly (Bloom, 1984). Most of the patients on these wards suffered from schizophrenia (Häfner & an der Heiden, 1988). The back wards were human warehouses filled with hopelessness. Staff members relied on straitjackets and handcuffs to deal with difficult patients. More “advanced” forms of treatment included medical approaches such as lobotomy (see PsychWatch below). Many patients not only failed to improve under these conditions but also developed additional symptoms, apparently as a result of institutionalization itself.

In the 1950s, clinicians developed two institutional approaches that finally brought some hope to patients who had lived in institutions for years: milieu therapy, based on humanistic principles, and the token economy program, based on behavioral principles. These approaches particularly helped improve the personal care and self-image of patients, problem areas that had been worsened by institutionalization. The approaches were soon adapted by many institutions and are now standard features of institutional care.

Milieu Therapy In 1953, Maxwell Jones, a London psychiatrist, converted a ward of patients with various psychological disorders into a therapeutic community—the first application of milieu therapy in a hospital setting. The premise of milieu therapy is that institutions can help patients by creating a social climate, or milieu, that promotes productive activity, self-respect, and individual responsibility. In such settings, patients are often given the right to run their own lives and make their own decisions. They may participate in community government, working with staff members to set up rules and decide penalties. Patients may also take on special projects, jobs, and recreational activities. In short, their daily schedule is designed to resemble life outside the hospital.

Since Jones’ pioneering effort, milieu-style programs have since been set up in institutions throughout the Western world. The programs vary from setting to setting, but at a minimum, staff members try to encourage interactions (especially group interactions) between patients and staff, to keep patients active, and to raise their expectations about what they can accomplish.

Research over the years has shown that people with schizophrenia and other severe mental disorders in milieu hospital programs often improve and that they leave the hospital at higher rates than patients in programs offering primarily custodial care (Paul, 2000; Paul & Lentz, 1977). Many remain impaired, however, and must live in sheltered settings after their release. Despite its limitations, milieu therapy continues to be practiced in many institutions, often combined with other hospital approaches (Borge et al., 2013). Moreover, you will see later in this chapter that many of today’s halfway houses and other community programs for people with severe mental disorders apply the principles of milieu therapy.

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The Token Economy In the 1950s, behaviorists discovered that the systematic use of operant conditioning techniques on hospital wards could help change the behaviors of patients (Ayllon, 1963; Ayllon & Michael, 1959). Programs that apply these techniques are called token economy programs.

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In token economies, patients are rewarded when they behave acceptably and are not rewarded when they behave unacceptably. The immediate rewards for acceptable behavior are often tokens that can later be exchanged for food, cigarettes, hospital privileges, and other desirable items, all of which compose a “token economy.” Acceptable behaviors likely to be included are caring for oneself and for one’s possessions (making the bed, getting dressed), going to a work program, speaking normally, following ward rules, and showing self-control. Researchers have found that token economies do help reduce psychotic and related behaviors (Swartz et al., 2012; Dickerson et al., 2005).

Some clinicians have questioned the quality of the improvements made under token economy programs. Are behaviorists changing a patient’s psychotic thoughts and perceptions or simply improving the patient’s ability to imitate normal behavior? This issue is illustrated by the case of a middle-aged man named John, who had the delusion that he was the U.S. government. Whenever he spoke, he spoke as the government. “We are happy to see you…. We need people like you in our service…. We are carrying out our activities in John’s body.” When John’s hospital ward converted to using a token economy, the staff members targeted his delusional statements and required him to identify himself properly to earn tokens. After a few months on the token economy program, John stopped referring to himself as the government. When asked his name, he would say, “John.” Although staff members were understandably pleased with his improvement, John himself had a different view of the situation. In a private discussion he said:

Critics of the behavioral approach would argue that John was still delusional and therefore as psychotic as before. Behaviorists, however, would argue that at the very least, John’s judgment about the consequences of his behavior had improved.

Token economy programs are no longer as popular as they once were, but they are still used in many mental hospitals, usually along with medication, and in many community residences as well (Kopelowicz et al., 2008). The approach has also been applied to other clinical problems, including intellectual disability, delinquency, and hyperactivity, as well as in other fields, such as education and business (Spiegler & Guevremont, 2015).

Milieu therapy and token economy programs helped improve the gloomy outlook for patients diagnosed with schizophrenia, but it was the discovery of antipsychotic drugs in the 1950s that truly revolutionized treatment for schizophrenia. These drugs eliminate many of its symptoms and today are almost always a part of treatment.

As you read earlier, the discovery of antipsychotic medications dates back to the 1940s, when researchers developed the first antihistamine drugs to combat allergies. The French surgeon Henri Laborit soon discovered that one group of antihistamines, phenothiazines, could also be used to help calm patients about to undergo surgery. Laborit suspected that the drugs might also have a calming effect on people with severe psychological disorders. One of the drugs, chlorpromazine, was eventually tested on six patients with psychotic symptoms and found to reduce their symptoms sharply. In 1954, chlorpromazine was approved for sale in the United States as an antipsychotic drug under the trade name Thorazine (Adams et al., 2014).

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Since the discovery of the phenothiazines, other kinds of antipsychotic drugs have been developed. The ones developed throughout the 1960s, 1970s, and 1980s are now referred to as “conventional” antipsychotic drugs in order to distinguish them from the “second-generation” antipsychotics (also called “atypical” antipsychotic drugs) that have been developed in more recent decades. The conventional drugs are also known as neuroleptic drugs because they often produce undesired movement effects similar to the symptoms of neurological diseases. As you saw earlier, the conventional drugs reduce psychotic symptoms at least in part by blocking excessive activity of the neurotransmitter dopamine, particularly at the brain’s dopamine D-2 receptors (Chun et al., 2014; Düring et al., 2014).

How Effective Are Antipsychotic Drugs? Research has shown that antipsychotic drugs reduce symptoms in at least 65 percent of patients diagnosed with schizophrenia (Advokat et al., 2014; Geddes et al., 2011). Moreover, in direct comparisons the drugs appear to be a more effective treatment for schizophrenia than any of the other approaches used alone, such as psychotherapy, milieu therapy, or electroconvulsive therapy. In most cases, the drugs produce at least some improvement within weeks (Rabinowitz et al., 2014); however, symptoms may return if the patients stop taking the drugs too soon (Razali & Yusoff, 2014). The antipsychotic drugs, particularly the conventional ones, reduce the positive symptoms of schizophrenia (such as hallucinations and delusions) more completely, or at least more quickly, than the negative symptoms (such as restricted affect, poverty of speech, and loss of volition) (Millan et al., 2014; Stroup et al., 2012).

The Unwanted Effects of Conventional Antipsychotic Drugs In addition to reducing psychotic symptoms, the conventional antipsychotic drugs sometimes produce disturbing movement problems (Kinon et al., 2014; Stroup et al., 2012). These effects are called extrapyramidal effects because they appear to be caused by the drugs’ impact on the extrapyramidal areas of the brain, areas that help control motor activity.

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The most common extrapyramidal effects are Parkinsonian symptoms, reactions that closely resemble the features of the neurological disorder Parkinson’s disease. At least half of patients on conventional antipsychotic drugs have muscle tremors and muscle rigidity at some point in their treatment; they may shake, move slowly, shuffle their feet, and show little facial expression (Geddes et al., 2011; Haddad & Mattay, 2011). Some also have related symptoms such as movements of the face, neck, tongue, and back; and a number experience significant restlessness and discomfort in their limbs.

Whereas most undesired drug effects appear within days or weeks, a reaction called tardive dyskinesia (meaning “late-appearing movement disorder”) does not usually unfold until after a person has taken conventional antipsychotic drugs for more than a year (Tenback et al., 2015; Advokat et al., 2014). This reaction may include involuntary writhing or ticlike movements of the tongue, mouth, face, or whole body; involuntary chewing, sucking, and lip smacking; and jerky movements of the arms, legs, or entire body. It is believed that more than 10 percent of the people who take conventional antipsychotic drugs for an extended time develop tardive dyskinesia to some degree, and the longer the drugs are taken, the higher the risk becomes (Achalia, 2014). Patients over 50 years of age seem to be at greater risk. Tardive dyskinesia can be difficult, sometimes impossible, to eliminate (Combs et al., 2008).

Today clinicians are more knowledgeable and more cautious about prescribing conventional antipsychotic drugs than they were in the past (see Table 12.3). Previously, when patients did not improve with such a drug, their clinician would keep increasing the dose; today a clinician will typically add an additional drug to achieve a synergistic effect, stop the drug and try an alternative one, or stop all medications (Li et al., 2014; Roh et al., 2014). Today’s clinicians also try to prescribe the lowest effective doses for each patient and to gradually reduce medications weeks or months after the patient begins functioning normally (Takeuchi et al., 2014).

Newer Antipsychotic Drugs As you read earlier, second-generation (“atypical”) antipsychotic drugs have been developed in recent decades. These include clozapine (trade name Clozaril), risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon), and aripiprazole (Abilify). As noted earlier, these drugs are received at fewer dopamine D-2 receptors and more D-1, D-4, and serotonin receptors than the conventional antipsychotic drugs (Advokat et al., 2014; Nord & Farde, 2011).

Second-generation antipsychotic drugs appear to be more effective than the conventional drugs (Advokat et al., 2014; Bianchini et al., 2014). Recall, for example, Cathy, the woman whom we met earlier, and how well she responded to risperidone after years of doing poorly on conventional antipsychotic drugs. Unlike the conventional drugs, the new drugs reduce not only the positive symptoms of schizophrenia, but also the negative ones (Millan et al., 2014). Another major benefit of the second-generation antipsychotic drugs is that they cause fewer extrapyramidal symptoms and seem less likely to produce tardive dyskinesia, although some of them produce significant undesired effects of their own (Young et al., 2015; Waddington et al., 2011).

Given such advantages, more than half of all medicated patients with schizophrenia now take the second-generation drugs, which are considered the first line of treatment for the disorder (Barnes & Marder, 2011). Many patients with bipolar or other severe mental disorders also seem to be helped by several of these antipsychotic drugs (Advokat et al., 2014).

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Before the discovery of antipsychotic drugs, psychotherapy was not really an option for people with schizophrenia. Most were too far removed from reality to profit from it. Today, however, psychotherapy is helpful to many such patients (Miller et al., 2012). By helping to relieve thought and perceptual disturbances, antipsychotic drugs allow many people with schizophrenia to learn about their disorder, participate actively in therapy (see MindTech below), think more clearly, make changes in their behavior, and cope with stressors in their lives. The most helpful forms of psychotherapy include cognitive-behavioral therapy and two sociocultural interventions—family therapy and social therapy. Often the various approaches are combined.

Cognitive-Behavioral Therapy As you read earlier, the cognitive explanation for schizophrenia starts with the premise that people with the disorder do indeed actually hear voices (or experience other kinds of hallucinations) as a result of biologically triggered sensations. According to this theory, the journey into schizophrenia takes shape when people try to make sense of these strange sensations and conclude incorrectly that the voices are coming from external sources, that they are being persecuted, or another such notion. These misinterpretations are essentially delusions.

With this explanation in mind, an increasing number of clinicians now employ a cognitive-behavioral treatment for schizophrenia that seeks to help change how people view and react to their hallucinations (Howes & Murray, 2014; Naeem et al., 2014). The therapists believe that if people can be guided to interpret such experiences in a more accurate way, they will not suffer the fear and confusion produced by their delusional misinterpretations. Thus, the therapists use a combination of behavioral and cognitive techniques:

These behavioral and cognitive techniques often help schizophrenic people feel more control over their hallucinations and reduce their delusional ideas. Can anything be done further to lessen the hallucinations’ unpleasant impact on the person? Yes, say new-wave cognitive-behavioral therapists, including practitioners of acceptance and commitment therapy.

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As you read in Chapters 2 and 4, new-wave cognitive-behavioral therapists believe that the most useful goal of treatment is often to help clients accept their streams of problematic thoughts rather than to judge them, act on them, or try fruitlessly to change them. The therapists, for example, help individuals with anxiety disorders to become mindful of the worries that engulf their thinking and to accept such negative thoughts as but harmless events of the mind (see pages 114–115). Similarly, in cases of schizophrenia, new-wave cognitive-behavioral therapists try to help clients become detached and comfortable observers of their hallucinations—merely mindful of the unusual sensations and accepting of them—while otherwise moving forward with the tasks and events of their lives (Bacon et al., 2015; Chien et al., 2014).

Studies indicate that the various cognitive-behavioral treatments are often very helpful to clients with schizophrenia (A-Tjak et al., 2015; Briki et al., 2014; Morrison et al., 2014). Many clients who receive such treatments report that they feel less distressed by their hallucinations and that they have fewer delusions. Indeed, they are often able to shed the diagnosis of schizophrenia. Rehospitalizations decrease by 50 percent among clients treated with cognitive-behavioral therapy.

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Family Therapy More than 50 percent of those who are recovering from schizophrenia and other severe mental disorders live with their families: parents, siblings, spouses, or children (Tsai et al., 2011; Barrowclough & Lobban, 2008). Generally speaking, people with schizophrenia who feel positive toward their relatives do better in treatment (Okpokoro et al., 2014). As you saw earlier, recovered patients living with relatives who display high levels of expressed emotion—that is, relatives who are very critical, emotionally overinvolved, and hostile—often have a much higher relapse rate than those living with more positive and supportive relatives. Moreover, for their part, family members may be very upset by the social withdrawal and unusual behaviors of a relative with schizophrenia (Friedrich et al., 2014; Quah, 2014).

To address such issues, clinicians now commonly include family therapy in their treatment of schizophrenia, providing family members with guidance, training, practical advice, psychoeducation about the disorder, and emotional support and empathy. In family therapy, relatives develop more realistic expectations and become more tolerant, less guilt-ridden, and more willing to try new patterns of communication. Family therapy also helps the person with schizophrenia cope with the pressures of family life, make better use of family members, and avoid troublesome interactions. Research has found that family therapy—particularly when it is combined with drug therapy—helps reduce tensions within the family and so helps relapse rates go down (Girón et al., 2015; Okpokoro et al., 2014).

The families of people with schizophrenia and other severe mental disorders may also turn to family support groups and family psychoeducational programs for encouragement and advice (Duckworth & Halpern, 2014). In such programs, family members meet with others in the same situation to share their thoughts and emotions, provide mutual support, and learn about schizophrenia.

Social Therapy Many clinicians believe that the treatment of people with schizophrenia should include techniques that address social and personal difficulties in the clients’ lives. These clinicians offer practical advice; work with clients on problem solving, decision making, and social skills; make sure that the clients are taking their medications properly; and may even help them find work, financial assistance, appropriate health care, and proper housing (Granholm et al., 2014; Ordemann et al., 2014). Research finds that this practical, active, and broad approach, called social therapy or personal therapy, does indeed help keep people out of the hospital (Haddock & Spaulding, 2011; Hogarty, 2002).

The broadest approach for the treatment of schizophrenia and other severe mental disorders is the community approach. In 1963, partly in response to the terrible conditions in public mental institutions and partly because of the emergence of antipsychotic drugs, the U.S. government ordered that patients be released and treated in the community. Congress passed the Community Mental Health Act, which provided that patients with psychological disorders were to receive a range of mental health services—outpatient therapy, inpatient treatment, emergency care, preventive care, and aftercare—in their communities rather than being transported to institutions far from home. The act was aimed at a variety of psychological disorders, but patients diagnosed with schizophrenia and other severe disorders, especially those who had been institutionalized for years, were affected most. Other countries around the world put similar sociocultural treatment programs into action shortly thereafter (Wiley-Exley, 2007).

Thus began several decades of deinstitutionalization, an exodus of hundreds of thousands of patients with schizophrenia and other long-term mental disorders from state institutions into the community. On a given day in 1955, close to 600,000 patients were living in state institutions; today fewer than 40,000 patients live in such facilities (Althouse, 2010). Clinicians have learned that patients recovering from schizophrenia and other severe disorders can profit greatly from community programs. As you will see, however, the actual quality of community care for these people has often been inadequate throughout the United States. The result is a “revolving door” pattern for many patients. They are released to the community, readmitted to an institution within months, released a second time, admitted yet again, and so on, over and over (Duhig et al., 2015; Burns & Drake, 2011).

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What Are the Features of Effective Community Care? People recovering from schizophrenia and other severe disorders need medication, psychotherapy, help in handling daily pressures and responsibilities, guidance in making decisions, social skills training, residential supervision, and vocational counseling—a combination of services sometimes called assertive community treatment (Keller et al., 2014). Those whose communities help them meet these needs make more progress than those living in other communities (Malm, Ivarsson, & Allebeck, 2014; Swartz et al., 2012). Some of the key features of effective community care programs are (1) coordination of patient services, (2) short-term hospitalization, (3) partial hospitalization, (4) supervised residencies, and (5) occupational training.

COORDINATED SERVICES When the Community Mental Health Act was first passed, it was expected that community care would be provided by community mental health centers, treatment facilities that would supply medication, psychotherapy, and inpatient emergency care to people with severe disturbances, as well as coordinate the services offered by other community agencies. When community mental health centers are available and do provide these services, patients with schizophrenia and other severe disorders often make significant progress (Burns & Drake, 2011). Coordination of services is particularly important for so-called mentally ill chemical abusers (MICAs), or dual diagnosis patients, individuals with psychotic disorders as well as substance use disorders (Drake et al., 2015; De Witte et al., 2014).

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SHORT-TERM HOSPITALIZATION When people develop severe psychotic symptoms, today’s clinicians first try to treat them on an outpatient basis, usually with a combination of antipsychotic medication and psychotherapy. If this approach fails, they may try short-term hospitalization—in a mental hospital or a general hospital’s psychiatric unit—that lasts a few weeks (rather than months or years) (Craig & Power, 2010). Soon after the patients improve, they are released for aftercare, a general term for follow-up care and treatment in the community.

PARTIAL HOSPITALIZATION People’s needs may fall between full hospitalization and outpatient therapy, and so some communities offer day centers, or day hospitals, all-day programs in which patients return to their homes for the night. Such programs provide patients with daily supervised activities, therapy, and programs to improve social skills. People recovering from severe disorders in day centers often do better than those who spend extended periods in a hospital or in traditional outpatient therapy (Bales et al., 2014). Another kind of institution that has become popular is the semihospital, or residential crisis center. Semihospitals are houses or other structures in the community that provide 24-hour nursing care for people with severe mental disorders (Soliman et al., 2008).

SUPERVISED RESIDENCES Many people do not require hospitalization but are unable to live alone or with their families. Halfway houses, also known as crisis houses or group homes, often serve individuals well (Lindenmayer & Khan, 2012). Such residences may shelter between one and two dozen people. Live-in staff members usually are paraprofessionals—lay people who receive training and ongoing supervision from outside mental health professionals. The houses are usually run with a milieu therapy philosophy that emphasizes mutual support, resident responsibility, and self-government. Research indicates that halfway houses help many people recovering from schizophrenia and other severe disorders adjust to community life and avoid rehospitalization (Hansson et al., 2002; McGuire, 2000).

OCCUPATIONAL TRAINING AND SUPPORT Paid employment provides income, independence, self-respect, and the stimulation of working with others. It also brings companionship and order to one’s daily life. For these reasons, occupational training and placement are important services for people with schizophrenia and other severe mental disorders (Johnsonn et al., 2014; Bell et al., 2011).

Many people recovering from such disorders receive occupational training in a sheltered workshop—a supervised workplace for employees who are not ready for competitive or complicated jobs. For some, the sheltered workshop becomes a permanent workplace. For others, it is an important step toward better-paying and more demanding employment or a return to a previous job. In the United States, however, occupational training is not consistently available to people with severe mental disorders.

An alternative work opportunity for people with severe psychological disorders is supported employment, in which vocational agencies and counselors help clients find competitive jobs in the community and provide psychological support while the clients are employed (Solar, 2014: Bell et al., 2011). Like sheltered workshops, supported employment opportunities are often in short supply.

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How Has Community Treatment Failed? There is no doubt that effective community programs can help people with schizophrenia and other severe mental disorders recover. However, fewer than half of all the people who need them receive appropriate community mental health services (Addington et al., 2015; Burns & Drake, 2011). In fact, in any given year, 40 to 60 percent of all people with schizophrenia and other severe mental disorders receive no treatment at all (NIH, 2014; Torrey, 2001). Two factors are primarily responsible: poor coordination of services and a shortage of services.

POOR COORDINATION OF SERVICES The various mental health agencies in a community often fail to communicate with one another. There may be an opening at a nearby halfway house, for example, and the therapist at the community mental health center may not know about it. In addition, even within a community agency a patient may not have continuing contacts with the same staff members and may fail to receive consistent services. Still another problem is poor communication between state hospitals and community mental health centers, particularly at times of discharge (Torrey, 2001).

To help deal with such problems in communication and coordination, a growing number of community therapists have become case managers for people with schizophrenia and other severe mental disorders (Mas-Expósito et al., 2014; Burns, 2010). They try to coordinate available community services, guide clients through the community system, and help protect clients’ legal rights. Like the social therapists described earlier, they also offer therapy and advice, teach problem-solving and social skills, ensure that clients are taking their medications properly, and keep an eye on possible health care needs. Many professionals now believe that effective case management is the key to success for a community program.

SHORTAGE OF SERVICES The number of community programs—community mental health centers, halfway houses, sheltered workshops—available to people with severe mental disorders falls woefully short (Zipursky, 2014; Burns & Drake, 2011). Moreover, the community mental health centers that do exist generally fail to provide adequate services for people with severe disorders. They tend to devote their efforts and money to people with less disabling problems, such as anxiety disorders or problems in social adjustment. Only a fraction of the patients treated by community mental health centers suffer from schizophrenia or other disorders marked by psychosis (Torrey, 2001).

There are various reasons for this shortage of services. The primary one is economic (Feldman et al., 2014; Covell et al., 2011). On the one hand, more public funds are available for people with psychological disorders now than in the past. In 1963 a total of $1 billion was spent in this area, whereas today approximately $171 billion in public funding is devoted each year to people with mental disorders (Rampell, 2013; Gill, 2010; Redick et al., 1992). This represents a significant increase even when inflation and so-called real dollars are factored in. On the other hand, rather little of the additional money is going to community treatment programs for people with severe disorders. Much of it goes instead to prescription drugs, monthly income payments such as social security disability income, services for people with mental disorders in nursing homes and general hospitals, and community services for people who are less disturbed. Today, the financial burden of providing community treatment for people with long-term severe disorders often falls on local governments and nonprofit organizations rather than the federal or state government, and local resources cannot always meet this challenge.

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What Are the Consequences of Inadequate Community Treatment? What happens to people with schizophrenia and other severe disorders whose communities do not provide the services they need and whose families cannot afford private treatment (see Figure 12.4)? As you have read, a large number receive no treatment at all; many others spend a short time in a state hospital or semihospital and are then discharged prematurely, often without adequate follow-up treatment (Burns & Drake, 2011; Gill, 2010).

Many of the people with severe mental disorders return to their families and receive medication and perhaps emotional and financial support, but little else in the way of treatment (Barrowclough & Lobban, 2008). Around 8 percent enter an alternative institution such as a nursing home or rest home, where they receive only custodial care and medication (Torrey, 2001). As many as 18 percent are placed in privately run residences where supervision often is provided by untrained staff—foster homes (small or large), boardinghouses, care homes, and similar facilities (Lindenmayer & Khan, 2012). Another 34 percent of people with severe disorders live in totally unsupervised settings. Some are equal to the challenge of living alone, but many cannot really function independently and wind up in rundown single-room occupancy hotels (SROs) or rooming houses, often located in poor neighborhoods. They may live in conditions that are substandard and unsafe, which may exacerbate their disorder (Bowen et al., 2015; Bhavsar et al., 2014).

Finally, a great number of people with schizophrenia and other severe disorders have become homeless (Ogden, 2014; Kooyman & Walsh, 2011). There are between 400,000 and 800,000 homeless people in the United States, and approximately one-third have a severe mental disorder, commonly schizophrenia. Many have been released from hospitals; others are young adults who were never hospitalized in the first place. Another 135,000 or more people with severe mental disorders end up in prisons because their disorders have led them to break the law (Morrissey & Cuddeback, 2008; Peters et al., 2008) (see MediaSpeak below). Certainly deinstitutionalization and the community mental health movement have failed these individuals, and many report actually feeling relieved if they are able to return to hospital life.

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The Promise of Community Treatment Despite these very serious problems, proper community care has shown great potential for assisting people in recovering from schizophrenia and other severe disorders, and clinicians and many government officials continue to press to make it more available. In addition, a number of national interest groups have formed in countries around the world that push for better community treatment. In the United States, for example, the National Alliance on Mental Illness (NAMI) began in 1979 with 300 members and has expanded to 200,000 members in more than 1,000 chapters (NAMI, 2014). Made up largely of families and people affected by severe mental disorders, NAMI has become not only a source of information, support, and guidance for its members but also a powerful lobbying force in state and national legislatures, and it has pressured community mental health centers to treat more people with schizophrenia and other severe disorders.

Today, community care is a major feature of treatment for people recovering from severe mental disorders in countries around the world. Both in the United States and abroad, well-coordinated community treatment is seen as an important part of the solution to the problem of severe mental dysfunctioning (Wise, 2014; Burns & Drake, 2011).

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