Recovery From Schizophrenia: Psychiatry And Political Economy

186 THE POLITICAL ECONOMY OF SCHIZOPHRENIAFaced with the need to accept a diagnosis of major mental illness (and itsassociated stigma and debased status), anyone with an internal sense of relativeworth and competence will experience dissonance (see Figure 8.1). In fact, thosewho accept a diagnosis of mental illness tend to be people with a sense of ill-being(dysphoria) and a poor self-image; the grandiose and euphoric reject the illnesslabel. 114 Cognitive dissonance theory predicts that those who choose to accept thediagnosis of mental illness will attempt to resolve their sense of dissonance byconforming to their new outcast status and to the stereotype of worthlessness;they will become more socially withdrawn and adopt a disabled role. In seekingto confirm the incurable and incapable features of their role, their symptoms ofpsychosis will tend to persist and they are likely to become dependent on thetreatment agency and others in their lives.Such patterns will be even more exaggerated if the patient’s stigmatized status ismade evident by discernible physical traits; at worst these may be the shuffle, rigidfacial expression and drooling secondary to the use of high doses of antipsychoticdrugs; at the least they may include the slow gait of the unemployed, devaluedindividual with nowhere to go and nothing to do.Under pressure to return to adequate functioning, symptoms of illness will tendto recur as a defense against mounting dissonance. However, gentle and gradualefforts that lead such individuals to demonstrate publicly that they can function ata more adequate level, may result in a change in their self-concept and amovement towards labeled but competent status. Cognitive dissonance theorythus helps explain the precarious balance of functioning that is found inrehabilitating the person with mental illness. High expectations for his or herlevel of achievement can lead the patient to a higher level of functioning anddecreased segregation and stigma, but they can also increase the risk ofexacerbating psychotic symptoms and of hospitalization. 115 We may now see whysuccess is so often frightening and stressful to people with psychosis.In contrast, those who initially reject the label and status of mental illness (andpsychiatric treatment) will usually attempt to maintain their previous occupationaland social status. Any social rejection they experience is likely to result in anincrease in grandiosity and even more aggressive avoidance of treatment. Strongefforts to compel such individuals to accept a diagnosis of mental illness mayresult in superficial compliance but little genuine change in their privately heldopinion; consequently they are likely to attempt to evade treatment at everyopportunity. However, gradually increasing involvement in a non-debasingtreatment program, coupled with a high degree of rationalization, may lead thesepeople to a limited compliance with treatment, provided a dissonant label ofmental illness is not forced upon them.Thus, the patient with “insight” will tend to function less well than expectedand may become excessively dependent, while the patient who functions wellwill be inclined to reject treatment. Cognitive dissonance theory gives the mentalhealth professional an explanation of the common observation that he or she oftenseems to be encouraging each patient to do the opposite of what the person wants