Annotated Bibliography:

The Invisible Village (culture and recovery in schizophrenia)

The Invisible Village is a talk I gave soon after moving from the Bronx to the Psychiatric Institute at Columbia. It is a first example of using anthropological studies of the course of schizophrenia in different societies to understand the impact of culture and local social environment on the course and outcome of the illness. I was new at this, and re-reading it now, I think I pulled my punches. I spoke about “the career” of the young person in our society as a hazardous undertaking which a first episode of schizophrenia derails into an illness. Young people in agricultural village societies do not have careers in this sense, and so can continue as hindered but not disabled members of the family work force.

Here’s what I would say today: The course and outcome of schizophrenia is extremely variable, and one of the important influences on this variability is the immediate social environment in which this potentially life-long illness occurs. For example, thought disorder causes less interference with role performance in agricultural village societies. For this reason, schizophrenia has a worse outcome in western industrial societies where its onset in late adolescence or early youth coincides with a developmental stage in which the culture expects rapid new learning of social roles. Absent this participation, the patient loses expected membership in education, work and marriage training, and becomes a non-person in the society.

There is evidence that this first-episode loss of role can be avoided by early intervention in cases that parents and teachers have identified as having early signs in grade school. But even after the first psychotic break has caused dropping out of our expected promotion of social class, favorable effects on outcome and course can result from social treatment programs. Early family and close network education about lowered expectations, plus support in designing life goals different from others, in recognition and expectation of slower social learning. At the time I wrote this paper, multi-family groups meting together after the first episode were the best example of “the invisible village,” but now there are many others: “housing first” active treatment programs, “recovery” programs and many more.

Even without such interventions, long term follow up from midlife onward shows independent living resembling retirement in more than half of cases. Some with special training and support (such as work-rehabilitation programs) achieve independent employment and responsibility. Growing up and learning just take longer, so it is important to provide places where that can happen.