I selected this book by Julian Leff for comment in a chapter of my edited collection, Critical Psychiatry, because it is seen as representative of modern social psychiatry. The argument I made was that it was not thoroughgoing enough in promoting a psychosocial conceptual understanding of mental illness. When I received the request to review the second edition of the book, I was interested to see whether there were any changes in the text.
Actually, the new edition is not much different, but that is not unusual for such revisions. There is an additional chapter on the dissolution of the asylums, describing the work of the Team for Assessment of Psychiatric Services (TAPS), which Julian Leff directed. This material was alluded to in the first edition, but Leff says he highlighted it now because ‘the transition from psychiatric hospitals to community-based care has been achieved’ (preface). It is noteworthy that there is no longer an active debate about whether traditional psychiatric hospitals should be run down because the process has been completed.
Among other minor changes, information about the importance of expressed emotion, about which Leff is well known for his contribution, has been expanded to include a useful table about the percentage of relatives of people with schizophrenia in different countries who have high expressed emotion. Data about the association of expressed emotion with physical illness have also been reinforced.
Leff includes information about some major studies published since the first edition on the importance of urbanisation and ethnicity in the aetiology of mental illness. He seems to place more emphasis now on isolation and lack of support as specific causal social factors. He is clear that measures to reduce the social isolation of African-Caribbean individuals offer ‘more chance of success in curtailing this epidemic of schizophrenia [in this ethnic group] than hoping for a breakthrough in the genetic field’ (p. 210).
Personally, I remain disappointed that it is insufficiently critical of genetic theories of the aetiology of mental illness and the evidence base for psychotropic medication. (Fundamentally, it adopts a stress-diathesis model rather than a truly psychosocial understanding of the origins of mental illness.) However, this is a well-written book that remains accessible to a non-academic readership.