CLINICAL HANDBOOK OF SCHIZOPHRENIA

55. Recovery 567ways of thinking about severe mental illness in general and about schizophrenia in particular.The following sections describe the context, development, and substance of a varietyof perspectives on recovery. Specifically, we briefly discuss four different meanings of recovery:(1) recovery as cure, (2) recovery as rehabilitation, (3) recovery from the traumaof mental illness and its aftermath, and (4) recovery as institutional change.THE MANY MEANINGS OF RECOVERYRecovery as CureIn the 1950s, the deterioration of 100-year-old state hospitals and the introduction of effectivepsychotropic medication encouraged policymakers to consider less restrictive andconfining living arrangements for persons with schizophrenia. Once people diagnosedwith the disease began to live their lives outside of institutional settings, a tremendous diversityin course and outcome in the illness became apparent. This heterogeneity in outcomehas now been confirmed consistently over the past 30 years of clinical research bystandardized rating scales for assessing symptoms and functioning, and rigorous longitudinaldesigns that followed people over time. These studies revealed how some of the peoplein these studies fell at either of the far ends of the spectrum, with some showing a classicKraepelinian deterioration in functioning, whereas many others showed no observablesigns or symptoms and no residual impairments from the disorder between 11 and 32years after onset. Given that symptoms are the classic marker of illness, these peoplecould be considered to have recovered. On this basis, recovery became a synonym forcure, similar to the typical definition of recovery from illness, implying that the personhas been restored, through whatever means, to the same presumably normal conditionthat existed prior to the onset of the illness.In this way, definitions of recovery as returning to a normal condition based on explicitcriteria of levels of symptoms imply that there is a point at which symptom remissionmight be said to have occurred. This definition has many advantages, such as beingreliable; clear; and relatively easy to define, measure, and link to levels of functioning andwell-being in other areas of life. Appearing never to have had a serious mental illness,such persons could be considered to have recovered from their schizophrenia in the samesense that people recover from a severe infection, a broken leg, or asthma.In addition to discovering this sense of full recovery, the longitudinal outcome researchdescribed earlier also painted a multidimensional picture of schizophrenia, identifyingseveral conceptually and empirically distinct domains of functioning. Some peoplerecovered function in one or more of these areas, while remaining impaired or symptomaticin other domains. For example, some could work in challenging jobs and live independently,while continuing to hear voices or to entertain delusions. Others might no longerexperience such symptoms at all, but still have moderate functional impairments insocial relationships and/or employment. Taking into account only the loosely linked natureof these distinct domains, clinicians used concepts of partial, social, symptomatic,and other definitions of recovery to describe these different outcomes. Thus, it becameclear that recovery was a multidimensional concept. Following are a number of conceptualizationsof recovery, each of which emphasizes different aspects.Recovery as RehabilitationRecovery as applied to schizophrenia and related disorders has often been interpreted asadapting rehabilitation principles developed in the area of physical disabilities to psychi-