The various stages of this study point towards a conclusion which is very difficult to resist—that a substantial proportion, though by no means all, of the morbidity shown by long-stay schizophrenic patients in mental hospitals is a product of their environment. The social pressures which act to produce this extra morbidity can to some extent be counteracted, but the process of reform may itself have a natural history and an end. We should like, in this final chapter, to discuss these propositions in detail, both in their theoretical and in their practical aspects, and also to consider their implications for the future of mental hospitals and related services.

We put forward, in Chapter 1, three theories which help to predict how schizophrenic patients will react in various social environments. The first differentiated three types of impairment which contribute to the end-state seen in chronic schizophrenia—‘premorbid’, ‘primary’ and ‘secondary’. The second was concerned with the ways in which ‘primary’ impairments might vary under different types of social influence. The third dealt with the origin and modification of ‘secondary’ impairments. The first part of our discussion will focus on certain hypotheses derived from these theories which we have been able to put to the test.

Interaction between clinical and social factors

POVERTY OF THE SOCIAL ENVIRONMENT AS A CAUSE OF CLINICAL DETERIORATION

The most important hypothesis under test is that certain aspects of the social environment actually cause clinical improvement or deterioration. The first step was to show, in Chapter 4, that, looked at from the patient's point of view, there was a certain uniformity in level of social stimulation.