562 CHAPTER 12
established the social policy of deinstitutionalization—trying to help those with severe
mental illness live in their communities rather than remain in the hospital. Not every-
one thinks that deinstitutionalization was a good idea, at least not in the way it has
been implemented. The main problem is that the patients were sent out into communi-
ties without adequate social, medical, or fi nancial support. It is now common in many
U.S. cities to see such individuals on street corners, begging for money or loitering,
with no obvious social safety net.
The good news is that some communities have adequately funded programs
to help people with chronic schizophrenia and other chronic and debilitating psy-
chological disorders live outside of institutions. Community care (also known as
assertive community treatment) programs allow mental health staff to visit pa-
tients in their homes at any time of the day or night (Mueser et al., 1998; Stein &
Test, 1980). Patients who receive such community care report greater satisfaction
with their care; however, such treatment may not necessarily lead to better out-
comes (Killaspy et al., 2006).Residential Settings
Some people with schizophrenia may be well enough not to need hospitalization
but are still suffi ciently impaired that they cannot live independently or with family
members. Alternative housing includes a range of supervised residential settings. At
one extreme is highly supervised housing, in which a small number of people live
with a staff member. Residents take turns shopping for and making meals. They also
have household chores and attend house meetings to work out the normal annoy-
ances of group living. Those able to handle somewhat more responsibility may live
in an apartment building fi lled with people of similar abilities, with a staff member
available to supervise any diffi culties that arise. In independent living, in contrast,
a staff member provides periodic home visits to patients living on their own. As pa-
tients improve, they transition to less supervised settings.Vocational Rehabilitation
A variety of programs assist people with schizophrenia to acquire job skills; such pro-
grams are specifi cally aimed at helping patients who are relatively high-functioning
but have residual symptoms that interfere with functioning at, or near, a normal
level. Those who are more impaired may participate in sheltered employment, work-
ing in settings that are specifi cally designed for people with emotional or intellectual
problems who cannot hold a regular job. Individuals in such programs may work
in a hospital coffee shop or create craft items that are sold in shops. Those who are
less impaired may be part of supported employment programs, which place individ-
uals in regular work settings and provide an on-site job coach to help them adjust
to the demands of the job itself and the social interactions involved in having a job
(Bustillo et al., 2001). Examples of supported employment jobs might include work
in a warehouse packaging items for shipment, or restocking items in an offi ce or a
store (“Project search,” 2006). What predicts how well a patient with schizophrenia
can live and work in the world? Researchers have found that an individual’s ability
to live and perhaps work outside of a hospital is associated with a specifi c cognitive
function: his or her ability to use working memory (Dickinson & Coursey, 2002).
Details of the treatment that the Genain sisters received are only available for their
time at NIMH, in the 1950s, when less was known about the disorder and how to treat
it effectively. During the sisters’ stay at NIMH, therapists tried to reduce the parents’
level of emotional expressiveness and criticism; however, such attempts do not appear
to have been effective. After their departure from NIMH, the sisters lived in a variety of
settings: Nora lived fi rst with Mrs. Genain, and subsequently in a supervised apartment
with Hester. Iris was less able to live independently and lived in the hospital, in super-
vised residential settings, or at home with Mrs. Genain; she died in 2002. Myra, long
divorced, generally lived independently; after Mrs. Genain died in 1983, Myra moved
into her mother’s house with her older son. Like Iris, Hester spent many years in the
hospital, then with Mrs. Genain. She lived with Nora in a supervised apartment until
she died in 2003 (Mirsky & Quinn, 1988; Mirsky et al., 1987, 2000).Deinstitutionalization was mandated without
adequate funding for communities to take care
of people with schizophrenia and other serious
mental illnesses. One result has been increased
poverty and homelessness among those with
such disorders.Joseph Schwartz/Corbis
Community care
Programs that allow mental health care
providers to visit patients in their homes at
any time of the day or night; also known as
assertive community treatment.