Recovery from schizophrenia: form follows functioning

The ascendance of the consumer move- ment’s definition of recovery has brought more heat than light to the growing awareness that persons with schizophrenia and other mental disabilities can be encouraged to set their own personal goals and educated to participate in an informed manner in decision-making regarding their treatment. Recovery, as defined by consumer advocates, is equated with: a) having a personally meaningful and satisfying life; b) being empowered to make one’s own decisions regarding life goals and treatment; c) having hope for the future; d) being at peace with oneself and one’s God; e) having a valued sense of integrity, well-being and self-respect. While these indicators of recovery are cogent homilies, I gainsay a sole reliance on these ambiguous and subjective attitudes for defining recovery. Adhering to these sensibilities alone would destroy the boundaries between those persons who are dependent upon others and remain disabled with persisting positive and negative symptoms vs. those who have achieved relatively normal work and social functioning with lifestyles of active participation as citizens of their communities. Just as in other medical diseases 1,2,3,4, recovery from schizophrenia should be recognized only when patients, usually through effective treatment and rehabilitation, no longer have symptoms so severe that they intrude on personal independence and, as a result, can retrieve a reasonable degree of normal functioning in their families, social lives, work, school, illness self-management, independent living and recreational activities. In other words, the form of recovery follows functioning 5. Through a series of focus groups of stakeholders in the mental health field (patients, psychiatrists and other mental health professionals, family members, active members of the National Alliance on Mental Illness and laypersons in the general population), a brace of functional criteria was developed to operationally embrace the concept of recovery 6. These included: a) symptoms low enough in severity and frequency so as not to impede everyday functioning; b) work in a competitive, market job or attending a normal school at least half time; c) reasonably cordial family relationships, recognizing that occasional family discord is normal; d) social relationships with at least one friend with whom one engages in social and recreational activities in normative community environments at least once every two weeks; e) independent living as defined by money management, illness management, self-care, personal hygiene within normal standards. In several studies, this definition of recovery was shown to significantly differentiate individuals with schizophrenia who had or had not achieved a functional lifestyle 7,8,9 and normal neurocognitive functions 10. In their incisive article, Bellack and Drapalski highlight the obfuscating and political nature of consumer views on recovery that are vague, not based on established psychological principles and refractory to an empirically reliable and valid definition. In an attempt to clothe these solipsistic definitions of recovery in objective, measurable ways and integrate them with academically respectable theories of behavior, the authors fixate on a social-cognitive model of recovery that is based on Bandura’s concept of self-agency and self-efficacy. While their attempt to articulate and validate those consumer views of recovery with an established psychological principle is noteworthy, it has the inadvertent effect of providing professional and scientific respectability to what remain subjective indicators that are not grounded in social norms. As Bandura 11 points out, “In efforts to serve all purposes, items in self-efficacy scales are usually cast in general terms divorced from specific situational demands and circumstances. This leaves much ambiguity about exactly what is being measured or the level of task and situation demands that must be managed. Scales of self-efficacy must be tailored to the particular domain of functioning that is the object of interest.” While Bellack and Drapalski identify self-efficacy as a mediator between attainment of functional goals and consumer notions of empowerment, hope and self-responsibility, it is not clear what additional explanatory power is provided by self-efficacy measures over and above functional attainment of social, family, work, school, friendship, dating, illness self-management and independent living domains. Furthermore, recent research has shown that there is a disconnect between the ability of persons to accurately forecast how they will feel in the future and how they actually do feel in future situations, thereby limiting the predictive validity of self-efficacy as a mediator for hope and personal satisfaction 12. In addition, items on most self-efficacy scales and the consumer domains of recovery encapsulated by the Maryland Assessment of Recovery in People with Serious Mental Illness (MARS) appear to be isomorphic, which would account for their statistical findings. While individuals with schizophrenia often gain confidence and optimism as they overcome obstacles to independence and social and employment success, a self-generating system of success breeding ever more motivation to strive for success in tackling ever more ambitious goals and action is a romantic conceptualization. On the contrary, for those of us working daily with persons having schizophrenia, each functional accomplishment – living independently, starting a job, returning to school, going on a date – is accompanied by stress, lack of confidence, fear of failure and rejection. All too often, as has been noted in a plethora of studies on supported employment 13 and other rehabilitation services, success is not cumulative, but rather pockmarked by failures and the need for ongoing supports with training and re-training in functional skills and problem-solving required for normative integration into community life. While there are obvious interactions between subjective attitudes of consumers and functional criteria of recovery, “it would be untenable to ignore the continued presence of psychotic symptoms or functional disability and inability of the person to resume expected social roles” 14. If recovery from schizophrenia and other disabling mental disorders is to contribute to the reduction of stigma toward the mentally ill and impetus to the adoption of person-centered, recovery-oriented and evidence-based practices by mental health service systems, recovery criteria must be able to differentiate individuals who are disabled from those whose symptom and neurocognitive impairments do not interfere with illness self-management, normal psychosocial functioning and non-deviant integration and active participation in community life.