TWO New York City researchers, Pat and Jake Cohen, undertook a very interesting study in the early 1980s. Both were statisticians in two different departments of psychiatry in the city. Together, they had written one of the primary textbooks on multivariate analysis. In another collaborative study, they looked at the composition of physician caseloads, including, but not limited to, psychiatry. What they found was startling.
Caseloads tended to be made up of two percent of the most seriously ill patients who were seen an average of 64 more times than anyone else in each case load. They called this phenomenon “The Clinician’s Illusion”1. Two percent sixty four more times! It would certainly change one’s perception about what was and was not possible for people’s recovery and would generate a different set of expectations.
And that is also what happened to me as a neurosurgical ICU nurse. I saw so many kids with brain tumors that it seemed to me that every third child in America had one. I would rush home and hug my own three children and bless the good fortune we had. I wrote up a list of these dreadful diagnoses and gave them to my local pediatrician who was a superb diagnostician. His response was: “Well, I see one of those kids once very ten years or so.”
He had a practice equal to that of three pediatricians and saw lots of children. Remember that in pediatrics, most patients are well and I was working in a tertiary setting where kids in the 2% had been referred from all over the world. I learned that I, too, had suffered from “The Clinician’s Illusion.” It had been all too easy to succumb to it. I suggest that many of our hard working clinicians in mental health systems have also been fooled by the illusion because they are systematically deprived of good outcome information about previous service users.
I believe that peer providers and other peers who are far along in their recovery process are the very best examples of an amazing process shown by people reclaiming their lives right in front of our noses. They have described many different phases involved in such a process. Phase One has been described as “feels confused, disconnected from others, powerless, and out of control.” Phase Two was defined as “coming to terms with disability and could live a satisfying life with a disability,” and Phase Three was living beyond the disability and “feels well connected to self and others in the living, learning, working environment and experiencing a sense of purpose and meaning in life.”2
Most clinicians, these days, are beginning to see and promote Phase Two but many still doubt the idea of living beyond the disability and reclaiming life. What clinicians are not so aware of is how very hard the work is for a participant to reclaim a life! People have said they are recovering from “loss of self, connection, hope, roles and opportunities, rebounding from devaluing, and disempowering programs, practices, and other environments in which there are acts of stigma and discrimination.” All of which has led to an “internalized sense of oppression and shame!”2
Spaniol, Gagne & Koehler go on to say that the amount of work to recover requires hard effort and a belief that it might be possible including the following: “taking stock and an active role, learning to rely on the self, finding supports, learning better coping and to love, increasing self-esteem and self-monitoring, building on reality, finding some kind of spirituality, and reclaiming hope.”2
Inch by inch, with two steps forward and one back, our old chronic system is beginning to reawaken to all sorts of new possibilities to help people learn to live beyond their struggles and to reclaim lives. Such clinicians and persons with the lived experience realize now that significant improvement and even full recovery may really be possible.
1) Cohen, P. & Cohen, J. (1984) The clinician’s illusion. Archives of General Psychiatry, 42 (12): 1178- 1182.
2) Spaniol, L., Gagne, C.,& Koehler, M. (1999). Recovery from serious mental illness: What it is and how to support people in their recovery. In R.P. Marinelli & A.E Dell Orto (Eds.) The Psychological and Social Impact of Disability (fourth edition).New York, Springer Publishing.
This essay is a revision of an editorial which was written by the author and published in RECOVERe-works (No. 73, July, 2011 pp. 1and 2) for the Center of Rehabilitation and Recovery of the Coalition of Behavioral Health Agencies in New York City.