In Reply: We appreciate the difficulties posed by Masland's questions, as well as the concerns raised by Dickerson in her commentary on our article in the May issue (1). They capture the very issues which moved us to write our article.
First, Masland argues that mental illness impairs a person's "ability to interact with others" and similar abilities. Although this may be true of some people with some mental illnesses some of the time, it is not true of most people with most illnesses most of the time. There is a much greater degree of heterogeneity in functioning, both within an individual and over time (2), which is why there are complexities involved in using a term such as recovery, which means different things to different people. But there simply are no data to support Masland's contention that these abilities are impaired in everyone who has a mental illness and that the impairments last for most of their lives.
Such concerns are relevant to a subgroup of persons with severe, persistent impairments. Rather than suggesting that recovery for this subgroup is "simply not possible," as Masland writes, or may "generate unrealistic expectations," as Dickerson commented, we suggest that it is precisely this subgroup for whom recovery "in" mental illness is most relevant and needed. This leads to our second response, which is related to the distinction between recovery and recovery-oriented care.
Masland and Dickerson appear to miss this distinction and the shift in perspective required, which is evident in Dickerson's conclusion that "learning to live better in the face of mental illness doesn't alter" the fact that "our science has not come even close to being able to cure or prevent" it. From the perspective of the person with the disorder, she has it backward. It is especially when the illness is most severe, and because we do not yet have a cure, that people who have these disabling disorders have no choice but to live in the face of them. This is the reality that takes priority in recovery-oriented care.
We thus are not failing "to take into account the cognitive and emotional effects of the disease" or "avoid[ing] the issue of the inability to interact as a caregiver with a care receiver," as Masland states. Rather, we are raising the question of how caregivers can most effectively respond to these very effects. In the past we have been immobilized by our lack of a cure, and we have conveyed a message of hopelessness to our clients and segregated people in artificial settings, expecting them to be cured before rejoining community life. This contradiction has led to demoralization, despair, and dependency.
An alternative is to stop insisting that people become cured first and refocus our efforts on how to help people find ways to live better lives in the face of the disability. This refocusing is one change that people with mental illness are advocating under the rubric of recovery-oriented care, as del Vecchio's commentary on our article demonstrated (3), and which suggests that the "inability to interact" has been at least as much on our part (the "caregiver") as it has been on the part of the person (the "care receiver"). If cognitive and emotional deficits are due to the disease that we are charged with treating, then is it not within the role of the treater to become a specialist in how to deal with these impairments, in the patient's life as well as in his or her relationship with the psychiatrist?
Research to prevent and cure mental illnesses should by all means continue; however, in the meantime our patients need to live their lives in the face of the illness. Once their rights to that life have been restored, there is much that we can do to support them in those efforts.
Dickerson FB: Disquieting aspects of the recovery paradigm. Psychiatric Services 57:647, 2006
Davidson L, McGlashan TH: The varied outcomes of schizophrenia. Canadian Journal of Psychiatry 42:34-43, 1997
Del Vecchio P: All we are saying is give people with mental illnesses a chance. Psychiatric Services 57:646, 2006