RTP: The Clinician's Illusion; Why Clinicians Don't See Enough Recovery

Why Don't Clinicians See Enough Recovery?
By Larry Davidson Recovery to Practice May 28, 2010

If so many people recover from serious mental illnesses, why is it that we don't see them? This is one of the most common questions raised by mental health professionals when confronted with the long-term outcome literature. That literature suggests that between 45-65% of people diagnosed with schizophrenia-the most severe of the severe mental illnesses-will recover from the disorder over time. This literature has now been around, and consistently replicated, since the 1970's, but still has not made its way into the training of most mental health professionals. So, many mental health professionals, when exposed to this body of research, ask the question above. If so many people get better, then why don't I ever see them? A reasonable enough question, to be sure, and one for which we fortunately have several answers.

The first answer comes from a husband and wife team of statisticians in the 1980's, Cohen and Cohen, who wrote the seminal paper cited below about what they described as the "clinician's illusion." I was first given a copy of this article by Courtenay Harding, the psychiatric nurse turned psychologist who has been responsible for carrying out the longest longitudinal study of schizophrenia in the United States, if not in the world, and who has been one of the few persistent advocates of recovery since long before it came into vogue. I was fortunate to take a seminar with Courtenay when I was a psychology intern, and have never looked at the world the same way since.

The "clinician's illusion" paper was one of the weapons Courtenay had in her arsenal for beating back the hordes of skeptical researchers and clinicians who insisted that her data could simply not be true. This also happened to be the response John Strauss, Courtenay's and my mentor, received when he tried to publish his first findings in the early 1970's showing that many people experienced improvements over time. The reviewers, and editor, rejected the paper, insisting that they already knew that recovery was not possible for people with schizophrenia.

What did the Cohen's argue? Based on fairly sophisticate d statistics, they showed that people who work in clinical settings, i.e., clinicians, see people who are ill. While this statement alone may seem obvious, its converse is less so, i.e., that clinicians do not see people who are, or when they are, well. Especially in the case of ambiguous and prolonged conditions, the Cohen's showed that clinicians tend to assume that people with such conditions are usually ill, and that these conditions are usually disabling, even though that may not always be the case. If I only see you when you are sick, I am going to assume that you are always sick. And if I work in a clinical setting, and therefore typically see people when they are sick, I am likely to draw the erroneous conclusion that the people I see are always sick. What I may not

stop to consider is that I may not be seeing them because they are in fact doing well.

In less ambiguous or better understood illnesses, there may be no such "illusion." For example, when my wife practiced as a pediatric nurse practitioner in an endocrinology clinic, her assumption when she didn't see a teenager in her clinic was that the teen was probably doing fine in managing his or her diabetes. When the teen got sick, then she would see him or her, either in the clinic or in the hospital, but otherwise odds were that things were basically okay.

What has been different in psychiatry is the legacy of the 100+ years during which people with serious mental illnesses were confined to institutions, often for the remainder of their adult lives. This period of institutionalization both gave birth to and perpetuated the belief that these illnesses were permanently disabling. As it turns out, what was permanently disabling was being confined to an institution, not the illnesses themselves. Since the end of that era, epidemiologic and longitudinal studies have found that many people do well over time, and that when they do well, they often see no reason to seek or utilize mental health services.

As a result, mental health professionals in fact do not see these people, at least not a s patients in public sector settings. They do, of course, encounter such people all the time, in the grocery store or mall, at the PTA or swim club meetings, at work and at social events, in their neighborhood, and at church, synagogue, or mosque. It's just that these people do not introduce themselves as having a history of mental illness, and if they don't disclose that history to you, you would have no other way of knowing. And given the stigma and discrimination that currently exist, why would they?

Article on Clinician's Illusion:

P. Cohen & J. Cohen. (1984). The clinician’s illusion. Archives of General Psychiat ry, 41, 1178–1182.

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A Selection of Outcome Studies from the Last 30 Years:

J.S. Strauss & W.T. Carpenter, Jr. (1972). The prediction of outcome in schizophrenia I: Characteristics of

outcome. Archives of General Psychiatry, 27:739‐746.

J.S. Strauss & W.T. Carpenter, Jr . (1974). The prediction of outcome in Schizophrenia II: Relationships

between predictor and outcome variables. Archives of General Psychiatry, 31:37‐42.

J.S. Strauss & W.T. Carpenter, Jr. (1974). Characteristic symptoms and outcome in schizophrenia.

Archives of General Psychiatry, 30: 429‐434)

J.S. Strauss & W.T. Carpenter, Jr. (1977). Prediction of outcome in schizophrenia III: Five‐Year outcome

and its predictors. Archives of General Psychiatry, 34: 158‐163.

L. Ciompi. (1980). The natural his tory of schizophrenia in the long‐term. British Journal of Psychiatry,

136: 413‐420.

C.M. Harding, G.W. Brooks, T. Ashikaga, J.S. Strauss, & A. Brier. (1987). The Vermont Longitudinal Study

of persons with severe me ntal illness, I: Methodology, study sample, and overall status 32 yea rs later.

American Journal of Psychiatry, 144: 718‐726.

C.M. Harding, G.W. Brooks, T. Ashikaga, J.S. Strauss, & A. Brier. (1987). The Vermont Longitudinal Study

of persons with severe mental illness, II: Long‐Term outcome of subjects who retrospectively Met DSMIII

criteria for schizophrenia. American Journal of Psychiatry, 144: 727‐735.

W.T. Carpenter, Jr. & J.S. Strauss. (1991). The prediction of outcome in schizophrenia IV: Eleven‐Year

follow‐up of the Washington IPSS Cohort. Journal of Nervous And Mental Disease, 9: 517‐525.