The duality of care: Finding the right balance

Recognizing the duality of care

In this article, I return to the notion of care in the medical and health fields, and more specifically to the importance of recognizing the duality of the care relationship: between technical care and relational care, between the treatment of disease and ‘caring for’ the person, and between the dimensions of cure and care. This distinction is classical and has long been familiar to clinicians, particularly in psychiatry, where it was the object of Winnicott’s well-known comments in his article ‘Cure’ (Winnicott, 1969). There, he already points to the risk that scientific medicine (particularly for specialists) may neglect the ‘care’ dimension, and he underscores the importance of maintaining the dual posture that he names ‘care–cure’ in medical care.

More recently, work on the ethics and theories of care developed in the field of moral and political philosophy (Gilligan, 1993; Noddings, 1986; Tronto, 1994) has reminded us not only of the importance and specificity of the dimension of ‘care’ but also of its tendency to be underestimated, devalued, made invisible, and delegated to less qualified and less recognized categories of professionals. This is without mentioning the gender inequalities in the distribution of ‘care’ tasks.

These insights seem to have had little direct impact on healthcare practices, as evidenced by the scant number of publications that explicitly reference this research (with the significant exception of research in nursing sciences or palliative care, which confirms the marginalization of the ‘caring for’ dimension, often delegated to paramedical professions or specified only in situations where curative care has been abandoned).

One can question the persistent neglect or reservation of healthcare professionals regarding the dimension of ‘care’ (as opposed to technical treatment, or ‘cure’). One might invoke the concern to legitimize or justify care practices on scientific grounds, which in fact ties them back to the ‘cure’ dimension. In psychiatric clinical practice and psychotherapeutic work, the technical and expert dimension (the knowledge of disorders) tends to be considered inseparable from the relational dimension, or more precisely, the two postures of care appear so closely intertwined in mental health care and their interweaving is so familiar to caregivers that it seems self-evident and unproblematic. Yet the entanglement of these two postures of care does not imply their fusion (or confusion), which could only be conceived at the expense of one of the components and invariably leads to minimizing the place of ‘care’. Nor does this entanglement imply that the two dimensions are always equally important in all situations; indeed, the opposite is true. Where acute pathologies are being treated, and all the more so in medical emergencies, the ‘cure’ dimension must predominate. This is not the case, however, for chronic illnesses, whose care primarily falls under the ‘care’ dimension, as Annemarie Mol (2008) has shown in particular in relation to the care of people with insulin-dependent diabetes. Their care falls under what she calls the logic of ‘care’, which she contrasts with the logic of choice. (We will return to this later.)

This contribution aims to show that, rather than seeking an integrated conception of care, it seems on the contrary preferable, and even necessary, to take full measure of the difference between these two dimensions of care, to understand their own logic – which are profoundly heterogeneous and, in certain respects, opposed – and finally to recognize that their necessary articulation is far from self-evident and in fact raises a series of questions, beginning with that of the respective importance or priority to be accorded, depending on the situation, to each dimension.

Taking the example of chronic psychiatric disorders, where my own professional experience lies, I will argue that care adapted to people living with these chronic disorders – so-called ‘psychosocial rehabilitation’ care, or more precisely recovery oriented care – falls primarily under the ‘care’ dimension, even though this is almost never how it is conceived or presented (which once again testifies to the persistent ignorance and devaluation of the ‘care’ dimension among health professionals). The specificity of this type of care – which numerous empirical studies recognize as the most effective and appropriate for people living with chronic disorders – can indeed be better understood if one acknowledges that it belongs to the logic of ‘care’, hence the importance of understanding its spirit and principles. A more fundamental reason still for recognizing and respecting this irreducible duality of care is that it derives from a more general, distinctly human duality in our relation to the world, to others, and ultimately to ourselves – a duality so central that it is one of the fundamental markers of the human in Helmuth Plessner’s philosophical anthropology (Plessner, 2019: 271–86).

We shall begin by illustrating this duality of care and the importance of ‘care’ by following Nathalie Zaccaï-Reyners’s analysis of care for older people in nursing homes (or Établissement d’hébergement pour personnes âgées dépendantes, EHPADs). The duality of the care relationship that she identifies in nursing homes – as a duality of cognitive-attentional style and hence of mode of relating to these persons – and the ‘care’ posture as the capacity for continuous adjustment to the other allowing for the restoration of a positive interaction echoes Hartmut Rosa’s thematization of a dual relation to the world and to others: on the one hand, an instrumental relation; and on the other hand, a relation of resonance. This duality in our relation to the world appears, in turn, as derived from a specifically human property which, according to Plessner, consists in having a kind of double relation to one’s environment and to oneself, both direct and indirect in that it takes into account the perspectives of others – what Plessner describes as the human being’s ‘eccentric’ (or decentered) positionality. Finally, we shall illustrate the duality of the care relationship and the prioritization of the ‘care’ dimension in the care of patients with chronic somatic and psychiatric illnesses.

Reflection on care in nursing homes (EHPADs)

In her compelling book Visite à l’EHPAD (2023), Zaccaï-Reyners turns a deeply personal and familiar experience – a visit to her grandmother after she entered a nursing home – into a profound meditation on care. The encounter occurred during lunch, not in the main dining room – reserved for those who could eat independently – but in a windowless space set aside for the most dependent and disoriented residents. Most were in wheelchairs, and staff moved among them patiently, often spoon-feeding those unable to feed themselves. The atmosphere was strained. Residents with impaired cognition struggled to comprehend the situation; many felt hurried, pressured, even terrified by gestures they perceived as intrusive or hostile. Some responded with protests, withdrawal, or refusal. Faced with this ‘resistance’, caregivers – anxious to ensure everyone was nourished – gently coaxed, and at times forced, their charges to feed them.

Besides the shock of discovering the desolate environment in which a beloved relative was now living, the limited, often degraded, and sometimes abusive – or experienced as such – relations with the nursing-home staff provoked a sense of unease that Zaccaï-Reyners describes very well, an unease heightened by a feeling of powerlessness and dismay at not knowing how to intervene without making the situation worse.

Her account of care reflects this dismay. Her brother, a filmmaker, decided to make a documentary about his grandmother’s life in the nursing home, filming, with the institution’s agreement, what he witnessed on visits occurring over a three-year period (Reyners, 2005). For Zaccaï-Reyners, a sociologist, this documentary served as an initial basis for analysis, supplemented by observational work in several such establishments, with the aim of better understanding what factors condition care relationships in nursing homes and what could transform them.

Zaccaï-Reyners observed a striking gap between the relational quality that she and her brother managed to maintain with their grandmother and the more tense relations with the nursing-home staff. Her grandmother was always warm to family members, but the staff found her ‘closed, resistant, difficult to support’; Zaccaï-Reyners wondered if they were seeing the same person (Zaccaï-Reyners, 2023: 43–4). Both this formulation and the situation it summarizes suffice to illustrate the relevance of a relational ontology in which the quality of the relationship determines who the person is, apparently even down to the personality traits attributed to them.

Zaccaï-Reyners notes that positive relationships are possible with certain caregivers, even in institutional settings and in situations rendered particularly difficult by the patient’s cognitive and psychological decline or by his or her defensive closure induced by interactions with caregivers that are experienced as abusive. She focuses in particular on situations – admittedly, somewhat exceptional – where entertainers come into nursing homes. Their performances often achieve powerfully calming effects and seem to make even withdrawn residents more outgoing. She attributes these effects to a particular quality of attention on the part of the artists – or caregivers – whose continuous adjustment of their proposals for interaction she observes. To characterize this form of attention, she draws on the distinction proposed by the aesthetic philosopher Jean-Marie Schaeffer between two cognitive styles to describe aesthetic attention (Schaeffer, 2015: 164). The convergent style is synonymous with ordinary attention: its aim is to minimize attentional cost in order to access relevant information. Speed and efficiency are thus prioritized in forming an overall coherence of what is perceived. The divergent style, characteristic of aesthetic attention, by contrast, seeks low selectivity in perceived information; it tends to defer the search for coherence in integrating data and to remain open to everything that can be perceived, refraining from anticipating what might be relevant: One accepts not understanding right away.

These two attentional styles – convergent and divergent – must be distinguished from the two types of cognitive operations that Guilford (1967) designates as convergent thinking and divergent thinking. Schaeffer’s distinction is intended to characterize aesthetic attention and remains confined to a specific mode of attentional and perceptual experience. By contrast, Guilford’s distinction has a broader scope and concerns two fundamental forms of thought: the first aims at the reduction of the space of possibilities, insofar as it seeks the determination of a single correct solution, whereas the second aims at the expansion of the space of possibilities. There are thus structural analogies between Schaeffer’s attentional duality and Guilford’s duality of forms of thought.

Zaccaï-Reyners’s analyses are compelling not merely because they associate care with a distinctive modality of attention – one that enables a continual adjustment, a genuine attunement to the other, thereby creating the conditions for authentic encounter and shared experience – but also because they further raise the question of whether such competence can be transmitted and cultivated so that caregivers within institutional settings might be systematically trained in its practice. The concluding chapter of her work turns to the organizational and managerial frameworks – themselves shaped by public policy – that may either foster or obstruct the development of this relational capacity. At this level, however, the situation appears decidedly unsatisfactory and seems to be evolving in a direction that is far from promising. Zaccaï-Reyners’s analyses thus show that what constitutes the quality of care in this context is the quality of the established relationship, and that this depends on a divergent attentional style linked to a willingness to adjust to the subtle expressions and reactions of the other. Only then can a living interaction occur, one in which each is present to the other and present to the situation.

This relational quality – this interpersonal attunement – closely approximates what Rosa terms a relation of resonance (Rosa, 2019). Reciprocal adjustment testifies to a mode of encounter in which experience is genuinely shared, along with the awareness of a possible reciprocal influence. Such resonance is vividly exemplified in the situations described by Zaccaï-Reyners: the performance of a cellist or a dancer demonstrates the capacity to re-establish contact and connection with patients for whom this possibility had seemed temporarily, or even definitively, lost. The sonorous vibrations of the cello and the improvised dance movements performed with and for elderly residents constitute paradigmatic instances of a resonant relation – both to the environment (the immersive musical space, the danced spatiality) and to the one who generates this surrounding world. This occurs not solely through the artistic quality of the performance but through the attentive care devoted to adjusting and continuously attuning the offering to those for whom it is intended. In this way, a reciprocal interaction is fostered and an atmosphere of well-being, even of shared delight, emerges. Certain formulations in Zaccaï-Reyners’s text come close to explicitly naming this dimension of resonance:

What particularly struck me in the unfolding and power of these interactions was the quality of the attention given to the patient … [by these artists]. An attention capable of capturing the patient to the point of modifying their states of consciousness, placing them in confidence, and ultimately touching them, moving them, sometimes even instilling in them something like a vibration that we might call life, strength, warmth, hope, or even love. (Zaccaï-Reyners, 2023: 56; my translation)

Beyond the emergence of this feeling of shared vibration, the dimension of reciprocity on which Rosa insists in characterizing relations of resonance is well described here: the person is moved and this, in turn, elicits emotion, which opens the care recipient up to the situation and to the other, thereby restoring a possibility of interaction and mutual influence. The caregiver’s or artist’s openness to the patient – manifested by a sustained effort of adjustment and tuning, by the concern to foster primary intersubjectivity (Trevarthen, 1979) – evokes in return the patient’s openness to what is being proposed, to which the patient responds with emotion, interest, and pleasure. This reciprocal openness allows for mobilization and revitalization.

There is, then, a convergence between Zaccaï-Reyners’s proposal to link ‘care’ to a divergent attentional style and Rosa’s notion of resonance. The difference between these two approaches is that the former emphasizes the caregiver’s role in establishing this authentic, reciprocal interaction, whereas the latter focuses on what constitutes the quality of the relationship, the lived experience of resonance. One can then ask about the factors that condition it, the types of relationship in which it can be experienced, and the effects it produces.

Care and the relation of resonance

Rosa’s work on resonance offers a way of thinking about care, even though the phenomenon of resonance is far from limited to care relationships, or even to interpersonal relations. It more generally characterizes a certain mode of relation to our surroundings, including to things and to ‘the world’ itself. According to Rosa, the experience of this particular relational modality is existentially fundamental, and it is perhaps in this sense that resonance sheds light on care – because it is a fundamental feature of human experience, just as care is.

The link between care and the resonant relationship becomes evident when considering, for example, early maternal care: the mother–baby interaction constitutes a paradigmatic situation of both a resonant relationship and a ‘care’ relationship. Between resonant relationship and care, the link appears intrinsic here, with resonance proving to be the condition for ‘care’, which is not limited to feeding and bodily care of the baby but absolutely requires this entry into an active and reciprocal relationship.

Should we then generalize this necessity of a dimension of resonance to every care relationship? If ‘good care’ requires – or even consists in – establishing a quality relationship, truly making contact, in a form of tuning and reciprocity, does it not correspond precisely to a relation of resonance? Is resonance not the condition of an authentic relationship in which ‘something passes’ or ‘happens’, in which an encounter occurs, a mutual opening, and in which a response can be perceived or felt?

The eccentric position of the human being and the duality of relation to the body, to the world, and to care

In his philosophical anthropology, Plessner (2019) considers that what is specific to the human being and distinguishes humans from other living beings is their ‘eccentric position’, which generates a double relation to one’s own body: an instrumental and distanced relation to ‘the body one has’ and a more intimate, necessarily engaged relation to ‘the body one is’. As Fuchs succinctly puts it, whereas animals can apprehend their environment only from a single perspective in which they are the focal point, and hence the center,

The human being has the capacity, as it were, to step outside himself and take on himself the perspective of an observer, which means that he can see himself with the eyes of others. This is what characterizes his ‘eccentric’ (decentered) position. He achieves this with the development of self-consciousness and reflection around the age of two or three. At this stage the child becomes aware of himself as an autonomous being; he learns to say ‘I’, to distinguish himself from others, and to establish a relation to himself. (Fuchs, 2021: 128; my translation)

We have seen that Rosa theorizes the dual register of relations to the world – between instrumental relations and relations of resonance – and that this duality echoes the duality found in care between ‘cure’ and ‘care’, and that Zaccaï-Reyners links this to the duality of attentional or cognitive style: convergent style and divergent style. It is very likely that all this is closely connected to the specifically human duality of the relation to one’s own body. Rosa explicitly raises this hypothesis:

Alienation denotes a relation of relationlessness in which subject and world find themselves inwardly unconnected from, indifferent toward, and even hostile to each other. This mode of relation itself contains the seeds of a relation of aggression – though one that, admittedly, first made possible the spectacular successes of scientific, technological, and economic progress. In my reading, the cultural achievement of modernity is that it has nearly perfected human beings’ ability to establish a certain distance from the world while at the same time bringing it within our manipulative reach. This sort of aggressive–distancing relationship to the world seems to me indispensable. Our capacity for it appears to be anthropologically innate, a precondition of being a human being, that ‘eccentrically positioned’ creature who not only can but is compelled to distance herself from herself and from her relationship to the world and in a way, to observe herself from the outside. (Rosa, 2020: 30)

The human being is thus both an embodied subjectivity, acting and experiencing pleasure or suffering, and in this sense directly engaged in the world, and also always a spectator of themselves so to speak (Carnevali, 2019), and therefore also in this disengaged, distanced relationship to themselves, to their own body, and to the world. According to Plessner, this ability to adopt this eccentric position is the one from which all other specifically human faculties can be derived: ‘[An] eccentric position makes possible in like manner, for example, the gift of speech and the need for clothing (thus, conceptualization and the consciousness of nakedness); or upright posture and religious consciousness; or the use of tools and interest in decoration’ (Plessner, 1970: 40).

However, the price to pay, so to speak, for this eccentric position and the resources it offers is the increased vulnerability of the human being, especially compared to animals, a vulnerability particularly to psychological disorders, as detailed by Fuchs. It is also important to understand that this eccentric position, unique to humans, manifests primarily in the relationship to oneself and particularly in the relationship to one’s own body, which, so to speak, becomes a dual relationship, marked by a duality:

The situation of my existence is ambiguous: as physical lived body – in the physical lived body. (Plessner, 1970: 36; original emphasis)

Plessner’s contribution is not only highlighting the importance of this distinction between the body one has, the objectified body (Körper), and the body one is, embodied subjectivity (Leib), but also emphasizing the problematic yet necessary articulation between these two experiences of the body, between which a balance must be found; otherwise, a discrepancy occurs between these two dimensions of lived experience. Plessner even speaks of ‘an actual break in his way of existing’. He is thus interested in the circumstances in which this balance is disrupted, as is the case, for example, in the situations discussed in his book Laughing and Crying (Plessner, 1970), when the dimension of control over emotional expression – i.e. the body as a means of expression – gives way to the direct, uncontrolled, irrepressible expression of the body one is, in situations where, as we commonly say, ‘the body takes over’.

[T]he reconciliation between having a body and being one must take place readily and quickly. Each individual must come to terms with this in his own way and in a certain sense can never come to terms with it. (Plessner, 1970: 37)

The experience of illness and of medical care makes this duality of bodily experience even more manifest: on the one hand, an objectifying relation to the body one has, reinforced by the gaze of medical expertise and by technical mediations (medical imaging, biological parameters), in short, a relation to the body ‘from the outside’ (and objective) with a view to control; on the other hand, a pathic relation to the body one is, suffering, functionally limited, whose failure directly affects the patient’s mood and even their capacity to judge and think.

It is easy to understand that Western medicine, grounded in scientific knowledge of disease and physiological functioning, entirely privileges the instrumental, distanced, objective relation to ‘the body one has’ – the perspective not only of health professionals but increasingly of patients themselves, who are invited to share this standpoint and mode of understanding their disorders. This raises the question of the articulation (or the gulf?) between this mode of relation to their bodies, made to appear foreign, and the perspective of a pathic, immediate, engaged relation to the body they are. The imbalance between these two forms of relation to the body, induced by medicine’s scientific (objectifying, instrumental) approach, necessarily leads to priority being given to the ‘cure’ dimension of care at the expense of ‘care’, which requires a different register of relation to the body.

If the duality of care between ‘cure’ and ‘care’ is the expression or consequence of the human being’s dual relation to his or her body – itself linked to this eccentric position – and if it is important, as Plessner emphasizes, to recognize the irreducible reality of these two modes of relation to the body and their necessary albeit problematic articulation, then we can infer that it is no less important to recognize the two dimensions of care, their articulation, and the necessary balance that must be sought between them. Inasmuch as scientific medicine privileges the instrumental and reifying relation to the body one has, is it not necessary to rebalance care practices by giving particular attention to the ‘care’ dimension – to a relation to the body and to the other that does not aim at mastery but at resonance, which presupposes recognition?

We thus arrive at a thesis similar to that developed, from other arguments, by theorists of care and care ethics. They denounce the underestimation and devaluation of the ‘care’ dimension and point instead to its importance not only in health care but, more generally, in the concrete everyday life of human beings, while emphasizing the political and cultural determinants of this devaluation of care.

It has often been noted that what makes it preferable not to translate the term ‘care’ into French, see (ffrench, 2024) is precisely the wish to preserve the balance between two dimensions that translation cannot maintain in a single word: on the one hand, a dimension of sensibility or perceptive and attentional disposition – to the singularity of persons and their values in ordinary life – conveyed by the terms ‘concern’ and ‘attention’; on the other hand, a dimension of intervention and thus of activity in response to perceived needs – conveyed by the terms ‘care’, ‘caring for’, or ‘taking care’ (Laugier, 2006). Zaccaï-Reyners’s conception of ‘care’ relies on a specific attentional–cognitive style that makes entering into relationship possible, with a relational quality that can be described as resonant in Rosa’s sense; Zaccaï-Reyners’s conception maintains the balance between receptive and active dimensions while distinguishing a cognitive register (of both attention and intervention) that differs from the objectifying register of medical science.

A reversal of priority between ‘care’ and ‘cure’ in care practices required for chronic somatic and psychiatric illnesses

There are reasons to think that we have not yet fully appreciated the gap between the paradigm of acute disease and that of chronic illness – particularly the fact that for chronic illness not only does the ‘care’ dimension matter, but it must in most cases prevail over the ‘cure’ dimension, reversing the hierarchy of priorities that characterizes medical care for acute diseases, where ‘cure’ predominates and relegates ‘care’ to the background, with the risk that it may sometimes be treated as negligible or optional.

In somatic medicine, this has been clearly recognized, at least in specialties primarily concerned with chronic illness, as illustrated by Mol (2008). Mol also stresses a form of duality in care made manifest in the context of caring for people living with insulin-dependent diabetes. As a health anthropologist, she analyzes the everyday care practices continuously experienced by people living with diabetes and observes that the technical and relational aspects do not oppose one another, and that patients actively participate in their own care. This leads her to describe this duality differently, replacing the distinction between technical care (cure) and relational care (care) with a distinction between the logic of choice and the logic of care, thereby shifting attention to other aspects of care. The logic of choice tends to reduce care to the moment of decision and to treat the patient as an autonomous and rational agent, invited to give informed consent to the decision or even to participate in it. In the logic of care, characteristic of the care required almost constantly in chronic illnesses like diabetes, we are not dealing with an abstract decision but with concrete practices, carried out and regulated largely by the patient. Far from being reduced to a decisive moment, care presupposes continuous attention and long-term involvement, with adjustments and micro-decisions made constantly in everyday life by patients themselves, with the advice and support of caregivers. Even in this brief presentation of Mol’s logic of care, we can discern a convergence with Zaccaï-Reyners’s distinction between two cognitive and attentional styles in the context of care in nursing homes, where needs and expectations differ. Mol’s duality of logics is akin to a duality of cognitive posture – comparable to that between theoretical and practical approaches – and is also compatible with Rosa’s duality of relation to the world between a rational, distanced, mastery-oriented relation and a practical, engaged, embodied relation that is capable of resonance.

In mental health and psychiatry, this duality of care is likewise manifest in the context of chronic psychiatric disorders, which over recent decades have led to the development of a duality between two paradigms of care. The traditional medical paradigm remains centered on the illness, its symptomatic expression, and treatment aimed at reducing symptoms and preventing relapse. It remains entirely relevant for acute illnesses and crisis situations. For people living with chronic psychiatric disorders, the attention of caregivers and of the patients concerned themselves is no longer focused solely on symptoms and their evolution but also on their impact on these persons’ everyday and social lives, whose future turns out not to depend solely on medical factors but also on psychological resources and the support provided by their social environment. In this case, care no longer has as its objective only symptom reduction but also the optimization of these persons’ quality of life, well-being, autonomy, and ultimately their personal and social prospects. So-called psychosocial rehabilitation practices reflect this reorientation of care goals.

The notion of recovery even more clearly embodies this paradigm shift by affirming the possibility of re-engagement in an active and socially satisfying life despite chronic illness and potential residual symptoms, and by making the aim of recovery the primary objective. The notion of recovery refers both to this possibility – which becomes the goal of care – and to the process of achieving it (or at least making progress toward it). Support for this process defines the paradigm of recovery-oriented care. Such practices – therapeutic education, support for social and professional integration, peer support, etc. – fall primarily under the ‘care’ dimension, understood in a sense entirely consistent with Zaccaï-Reyners’s conception: centered on restoring quality relationships and referring to a cognitive and attentional style distinct from the posture of medical rationality, or in Rosa’s terms, to a type of authentic, resonant relations that belong to a register different from the instrumental, rational relation to illness and to the diseased body that remains the posture of the medical expert.

A synthesis of a large number of qualitative studies conducted with people who have experienced psychiatric disorders and a subsequent recovery trajectory has identified dimensions that these individuals consider important in their recovery process (Leamy et al., 2011). These five dimensions are represented by the acronym CHIME: Connectedness, Hope, Identity, Meaning, Empowerment. We can interpret this result by considering that all five dimensions express the restoration of authentic, resonant relationships: with others (Connectedness), with oneself (Hope: restoring a positive relation to one’s future; Identity: reconstructing a positive identity that replaces that of a chronic mental patient), and with the world (Meaning: restoring meaning is linked to the restoration of a relation to a world that ‘speaks to us’; Empowerment: experiencing one’s capacity to act is one of the conditions of a resonant relation to the environment on which Rosa insists). It is often emphasized that recovery-oriented practices both rely on and aim to promote restoration of the relational dimension.

Once the profound difference between these two approaches (medical and recovery-oriented) has been clearly established, the question then arises as to how they can be articulated and whether they are compatible. Their heterogeneity is such that Davidson and colleagues were already asking in 2009 whether combining these two approaches might be compared to mixing oil and water, or rather oil and vinegar (Davidson et al., 2009). It is striking that this question is raised again in a recent article in The Lancet Psychiatry by authors well-known for their numerous and long-standing contributions to the notion of recovery (Speyer, Roe, and Slade, 2025). These authors deem it useful to recall that: ‘the recovery approach and the medical paradigm are founded on fundamentally different principles’ (ibid.: 799), and they add that insufficient conceptual understanding of the differences between these approaches, of their specificities, and their own principles leads in practice to a renunciation of the recovery approach, enabling the traditional medical paradigm to maintain its dominant position:

We agree with many critics that the original ideology of recovery is often co-opted into a diluted and unchallenging form, leaving mental health-care institutions largely unchanged. We hope that a deeper conceptual understanding of the principles underlying both recovery and the medical paradigm, as outlined in this Personal View, will enrich future dialogues and further support the shift towards recovery-oriented ideologies for organisations seeking to adopt this approach. (Speyer, Roe, and Slade, 2025: 799)

To clarify conceptually the difference between these two approaches (medical and recovery-oriented), the authors recall that they do not rest on the same norms and values (medicine privileges the principles of beneficence and non-maleficence, whereas the recovery approach prioritizes autonomy and justice) nor on the same ontology of mental disorders (naturalist vs. normativist conception of disorders) or on the same epistemology (objective vs. subjective, nomothetic vs. idiographic, quantitative vs. qualitative). Once the profound difference or heterogeneity of these approaches has been recognized and understood, the question of their articulation and compatibility returns. Without being able to detail their response here, let us note that, faced with the risk that an integrative conception of care will lead to downplaying the recovery perspective in favor of the dominant medical one, they propose a ‘non-integrative pluralism’ that accepts that several independent explanations can coexist without necessarily having to be integrated, adding that pluralism presupposes a form of epistemic humility and openness to other perspectives. We are struck by the convergence between the central argument of these authors concerning mental health care and the conception of care presented in this essay. In both cases the importance of truly recognizing the duality of care is emphasized by conceptually grounding what characterizes each of the two care postures (or perspectives or paradigms); otherwise, one of the perspectives risks being minimized or neglected – and it is always the posture of ‘caring for’ or recovery that is downgraded.

If it is important to make a conceptual distinction between these two care postures is also because in practice they are almost always combined, albeit in different proportions depending on the situation, and are often so closely intertwined as to seem inseparable. The quality of care would thus depend on adjusting the balance between these two dimensions according to situations and moments in the care trajectory, knowing in particular when and how the ‘caring for’ dimension should prevail. As a way of illustration of this interweaving and interdependence of care postures in psychiatric rehabilitation practices, practices inspired by cognitive behavioral therapy – scientifically validated and based on precise protocols – would appear to exemplify a medically inspired practice belonging to the ‘cure’ posture (aiming at control, efficiency, etc.). Yet by engaging with the details of patients’ lived situations, these practices allow adjustment to persons, to their concrete daily difficulties, and even to their specific needs, thereby meeting the requirements of ‘caring for’. In certain circumstances, high-quality technical care generating the patient’s trust – where this is the patient’s primary expectation – proves to be the condition for the emergence of the ‘caring for’ dimension. The art of care, or what constitutes its quality, would thus be the capacity to adjust these two postures of care as precisely as possible and to master their interweaving, even to draw benefit from it. This entanglement, however, as we have said, does not imply fusion of these dimensions of care, which would occur at the expense of the ‘caring for’ dimension. Rather, it calls, at the theoretical level, for specification of each dimension, of their priorities, and of their own logic – and it is precisely to this specification that the medical humanities contribute.

Concluding remarks on the recent history of conceptions of care

The clinical situations examined in this essay – selected to exemplify the duality of care, namely dependent older adults residing in nursing homes, individuals living with insulin-dependent diabetes, and persons affected by chronic psychiatric disorders – have led us to acknowledge that this duality assumes distinct configurations, or at least is conceptualized and described in markedly different ways across these settings. Yet each of these contexts reveals common features associated with the duality of care: on one side, the stance of medical expertise; and on the other, a posture of care oriented toward the person rather than the disease – one that foregrounds an engaged and embodied relational mode, attentive to the practical dimensions of everyday life and to the individual’s own priorities. This posture stands in contrast to the objectifying, rational, distanced, and disengaged stance characteristic of medical expertise.

To underscore the duality inherent in health care is to recognize that its relevance remains largely underappreciated, owing to the prevailing prioritization of medical expertise (the ‘cure’ dimension) and to the insufficient recognition and conceptual articulation of the posture of ‘caring for’. This is so despite the substantial contributions of the medical humanities, which have recently reaffirmed its importance and shed light on the reasons for its systematic neglect and devaluation. This asymmetry supports our hypothesis that the duality of care may be understood as a particular instantiation of a more general duality in modes of relating to the world (and to others): between an instrumental, mastery-oriented, distanced, and disengaged relation, and, in contrast, a relation of resonance, interdependence, and engagement, as theorized by Rosa. Rosa further suggests that this tension constitutes a defining feature of contemporary culture and its economic and political orientations, which tend to privilege instrumental and mastery-oriented relations to the world, except within the private or intimate affective sphere, where relations of resonance prevail and the value of caring is more readily acknowledged.

Although the present inquiry has not adopted a historical framework, it nonetheless prompts at least one historical observation. It is noteworthy that, in a roughly contemporaneous yet relatively independent fashion, a theoretical interest in the dimension of ‘caring for’ has emerged – most visibly through the development of care ethics and care theories – while at the level of medical practice, the rise of the chronic disease paradigm has brought about a transformation of care that may be described as a renewed centrality of the ‘caring for’ dimension. Mol has demonstrated this with respect to chronic somatic conditions; and in mental health, the recovery paradigm illustrates, in its own way, this shift toward ‘caring for’, including toward self-care. In line with many others, we hope to contribute to showing that the insights of the medical humanities – into the duality of care and into the necessity, as well as the inherent difficulty, of calibrating the balance between the care postures – may support the ongoing evolution and improvement of care practices.