Incomprehensibility in the narratives of individuals with a diagnosis of schizophrenia

Social Positioning Analysis as a Qualitative Methodology to Study Identity Construction in People Diagnosed With Severe Mental Illnesses

Severe mental illnesses (SMI) in general, and schizophrenia in particular, have been characterized as alterations of the experience of self and identity. When first diagnosed with SMI, the subjective experiences and specific narrative challenges faced by this population are particularly important. Therefore, qualitative approaches which allow to analyze these subjective experiences should be developed. This article presents in detail a specific method, called Social Positioning Analysis, which makes the complexity of narratives and life stories with multiple turning points understandable. To develop this methodological proposal, it has been taken into account the performative aspects of social interaction in which narratives are constructed. The methodology has previously been used in other health contexts and is innovative in the field of mental health. Linguistic criteria, definitions, and multiple examples are included to facilitate its application, as well as some reflections about its potential and possible benefits.

The impact of employment on recovery among individuals who are homeless with severe mental illness in the Vancouver At Home/Chez Soi trial

OBJECTIVE

To assess impact of employment on recovery in a sample of adults from Vancouver At Home (VAH) study, who were homeless and were diagnosed with severe mental disorders.

METHODS

The VAH included two randomized controlled trials investigating the effect of housing first with support intervention in vulnerable population. Employment was assessed at baseline and during the follow-up using Demographics, Housing, Vocational, and Service Use History (DSHH), and Vocational Timeline Follow-Back (VTLFB) self-report questionnaires, respectively. Recovery was examined using Recovery Assessment Scale (RAS) at baseline and at 24-month follow-up visit. Multivariable regression models were built to examine: (1) the effect of current employment at baseline on RAS score at baseline, and RAS score at 24-month follow-up visit; and (2) and to examine the cumulative effect of recent employment over 8 follow-up visits on RAS score at 24-month visit. Cumulative effect of employment over the follow-up visits was weighted by recency using a pre-specified weighting function.

RESULTS

Employment at baseline was associated with an increase in recovery score at baseline [8.06 (95% CI 1.21, 14.91); p = 0.02], but not with recovery score at 24-month follow-up visit [3.78 (-4.67, 12.24); p = 0.37]. Weighted cumulative effect of employment over 8 follow-up visits was associated with increase in RAS score at 24-month follow-up visit [8.33 (1.68, 14.99) p = 0.01].

CONCLUSION

Employment is associated with an increase in recovery. Our result suggests a dual effect of employment on recovery, an immediate effect through current employment, and a long-term effect of cumulative employment.

[The concept of narrative insight in schizophrenia: A systematic review]

AIM

The aim of this systematic revue of literature is to examine articles dealing with the narrative insight (patient's explanatory models of his difficulties) in patients suffering from schizophrenia. In addition to the theoretical interest of this work, it would make it possible to better adjust the clinical practices concerning the stories of patients about their disorders.

METHOD

A study was conducted using the databases ScienceDirect, Medline, PsychInfo and PubPsych using the key words "narrative insight", "cultural insight", "subjective insight", "narrative awareness", "mental illness", and "psychiatric disorder". This search by keywords led to eighty-six results; abstracts of all the articles were consulted. Then the authors selected and studied all articles corresponding to inclusion criteria and compared their results and reached agreement by consensus in case of difference. The theme of the study was to focus on the concept of narrative insight or any other close concept mentioning an explanatory model of mental and/or psychiatric disorders, moving away from the biomedical model. Nine articles were selected based on the inclusion criteria (articles published in peer reviewed journals, where the both the resume and article are accessible; articles dealing with narrative insight of people suffering from schizophrenia).

RESULTS

The authors of these articles agree that awareness of mental illness, insight, is a narrative act in which people give a personal meaning to their disorder. The most popular biomedical model used has many limitations and is the subject of many controversies. Results of the conducted study suggest considering narrative insight as adaptive strategies to mental illnesses. Indeed the process of narrative insight essentially consists in the patient adapting his life story to his conceptions and his values. To tell the story of one's own troubles with one's own values and beliefs gives meaning that helps protect identity and give back hope. This concept is considered to be dynamic and multidimensional. In addition, studies highlight its positive effects including the simultaneous presence of several models, which would have a greater favorable impact on the prognosis than the medical explanation alone.

CONCLUSION

It seems necessary to take into account the concept of narrative insight in order to evaluate insight of patients suffering from mental illness. This implies that the evaluation methods of insight as well as the clinical practice must evolve to adapt to the culture and subculture of the patient. This could have beneficial effects on the well-being of patients, therapeutic relations, access to treatment as well as psychiatric research, as well as limit controversies around this topic. It would be interesting to confirm this new conception of insight and the therapeutic relations by carrying out new studies as well as by starting to take it into account in patient care.

Characteristics of mental health recovery narratives: Systematic review and narrative synthesis

BACKGROUND

Narratives of recovery from mental health distress have played a central role in the establishment of the recovery paradigm within mental health policy and practice. As use of recovery narratives increases within services, it is critical to understand how they have been characterised, and what may be missing from their characterisation thus far. The aim of this review was to synthesise published typologies in order to develop a conceptual framework characterising mental health recovery narratives.

METHOD

A systematic review was conducted of published literature on the characteristics of mental health recovery narratives. Narrative synthesis involved identifying characteristics and organising them into dimensions and types; and subgroup analysis based on study quality, narrator involvement in analysis, diagnosis of psychosis and experience of trauma. The synthesis was informed by consultation with a Lived Experience Advisory Panel and an academic panel. The review protocol was pre-registered (Prospero CRD42018090188).

RESULTS

8951 titles, 366 abstracts and 121 full-text articles published January 2000-July 2018 were screened, of which 45 studies analysing 629 recovery narratives were included. A conceptual framework of mental health recovery narratives was developed, comprising nine dimensions (Genre; Positioning; Emotional Tone; Relationship with Recovery; Trajectory; Use of Turning Points; Narrative Sequence; Protagonists; and Use of Metaphors), each containing between two and six types. Subgroup analysis indicated all dimensions were present across most subgroups, with Turning Points particularly evident in trauma-related studies.

CONCLUSIONS

Recovery narratives are diverse and multidimensional. They may be non-linear and reject coherence. To a greater extent than illness narratives, they incorporate social, political and rights aspects. Approaches to supporting development of recovery narratives should expand rather than reduce available choices. Research into the narratives of more diverse populations is needed. The review supports trauma-informed approaches, and highlights the need to understand and support post-traumatic growth for people experiencing mental health issues.

Older and Younger African Americans' Story Schemas and Experiences of Living with HIV/AIDS

This paper reports findings from a study that compared older (n = 21, ≥ age 50) and younger (n = 96, ≤ age 49) African Americans' stories (N = 117) of living with HIV/AIDS to determine how they make sense of the experience. The purpose was to: (1) identify and describe the cultural models African Americans use to inform their stories of living with HIV/AIDS, and (2) to compare older and younger adults' HIV stories. To characterize the cultural models engaged in the telling of these HIV stories, we conducted schema analysis. Analyses documented six diverse schemas, ranging from "Stages of Grief", "12 Steps", "Wake Up Call", "Continuity of Life", to "Angry and Fearful", "Shocked and Amazed". Comparison conducted by age group showed older adults more frequently expressed their story of living with HIV as "Stages of Grief" and "Continuity of Life", whereas younger adults expressed their stories as "12 Steps" and "Wake Up Call". Findings contribute by documenting African American stories of living with HIV/AIDS, important heterogeneity in cultural schemas for experiences of living with HIV and differences by age group. These findings may help by identifying the cultural resources as well as challenges experienced with aging while living with HIV/AIDS for African Americans.

Recovery and creative practices in people with severe mental illness: evaluating well-being and social inclusion

PURPOSE

This mixed (quantitative-qualitative) study evaluates the impact of an artistic workshop on a group of people with severe mental illness (SMI). This study focuses on the impact of creative practices on well-being and social inclusion outcomes.

METHOD

After participating in a creative workshop, 31 people diagnosed with a SMI completed pre/post-intervention measures, namely, the Warwick-Edinburgh Mental Well-Being Scale and the Social Inclusion questionnaire. It was applied in two-way repeated measures analysis of variance. The statistic Wilcoxon and Kruskal-Wallis were applied for non-parametric data to measure pre/post-test effects and workshop experience effects, respectively. In addition to quantitative measures, one observer participated in each workshop that ran in parallel in order to deepen and triangulate quantitative outcomes.

RESULTS

The qualitative and quantitative results show that social inclusion improved in a significant way with an important size effect. Psychological wellbeing increased significantly with a low size effect.

CONCLUSIONS

In accordance with these results, creative practices with people diagnosed with SMI are recommended. In order to increase the impact of these interventions, it is recommended to utilize public space away from clinical environments and to include people without SMI in creative activities together with SMI patients. Implications for Rehabilitation: Creative practices can significantly improve social inclusions and well-being in people with severe mental illness. Participating in creative workshops helps to elaborate personal meanings and promote recovery. Creative practices in mental health services can challenge professional roles and institutional practices. Participation of people with and without severe mental illness engaged together in artistic activities can decrease public stigma.

Does Employment Promote Recovery? Meanings from Work Experience in People Diagnosed with Serious Mental Illness

Employment has been highlighted as a determinant of health and as an essential milestone in the recovery process of people with serious mental illness. Different types of programs and public services have been designed to improve the employability of this population. However, there has not been much interest in the meanings attributed to these experiences and the negative aspects of work experience. In this research, we explored the meanings that participants attributed to their work experience and the impact of work on their recovery process. Research participants lived in Andalusia (Spain), a region in southern Europe with a high unemployment rate. Two versions of a semi-structured interview were designed: one for people who were working, and one for unemployed people. Participants' narratives were categorized according to grounded theory and the analyses were validated in group sessions. Apart from several positive effects for recovery, the analysis of the narratives about work experience outlined certain obstacles to recovery. For example, participants mentioned personal conflicts and stress, job insecurity and meaningless jobs. While valid, the idea that employment is beneficial for recovery must be qualified by the personal meanings attributed to these experiences, and the specific cultural and economic factors of each context.

Impaired coherence of life narratives of patients with schizophrenia

Self-narratives of patients have received increasing interest in schizophrenia since they offer unique material to study patients' subjective experience related to their illness, in particular the alteration of self that accompanies schizophrenia. In this study, we investigated the life narratives and the ability to integrate and bind memories of personal events into a coherent narrative in 27 patients with schizophrenia and 26 controls. Four aspects of life narratives were analyzed: coherence with cultural concept of biography, temporal coherence, causal-motivational coherence and thematic coherence. Results showed that in patients cultural biographical knowledge is preserved, whereas temporal coherence is partially impaired. Furthermore, causal-motivational and thematic coherence are significantly impaired: patients have difficulties explaining how events have modeled their identity, and integrating different events along thematic lines. Impairment of global causal-motivational and thematic coherence was significantly correlated with patients' executive dysfunction, suggesting that cognitive impairment observed in patients could affect their ability to construct a coherent narrative of their life by binding important events to their self. This study provides new understanding of the cognitive deficits underlying self-disorders in patients with schizophrenia. Our findings suggest the potential usefulness of developing new therapeutic interventions to improve autobiographical reasoning skills.

"My life as it is has value": narrating schizophrenia in later years

I used thematic narrative analysis, informed by the developmental life course perspective, to formulate a line of semistructured questioning for interviews with 6 older adults who experienced ongoing symptoms of schizophrenia. From the 31 resulting interviews and 38 observation points, I developed life history narratives that yielded findings across four shared core themes. In this article I present my findings on the theme of narrative insight into schizophrenia in later years. Whereas only 2 of the participants had clinical insight into their mental illness, all had developed personal stories about their lives with schizophrenia. I discuss the significance of the shared narrative profile and the importance of using narrative insight to develop more effective clinical practices and to focus future research with older adults with schizophrenia.

Addressing methodological and ethical challenges of qualitative health research on persons with schizophrenia and bipolar disorder

Qualitative studies of persons with schizophrenia and bipolar disorder may affect clinical practice and social policy. However, methodological and ethical challenges may present during studies of persons with these specific mental illnesses. The purpose of this paper is to increase transparency about how researchers addressed these challenges during a recent grounded theory study about engagement in primary care. As the researchers addressed the challenges, they increased understanding about persons with schizophrenia and bipolar disorder. They also gained insight about the challenges of studying persons with these specific mental illnesses and about the rigor and credibility of qualitative methods.

Metacognition and social cognition in schizophrenia: stability and relationship to concurrent and prospective symptom assessments

OBJECTIVE

Schizophrenia has been linked with deficits in the ability to form complex representations about oneself and others. Less clear is whether these deficits are stable over time, and whether they are related to symptoms.

METHOD

We assessed metacognition capacity, affect recognition, executive function, and symptoms at baseline and 6 months later for 49 adults with schizophrenia.

RESULTS

Paired t tests revealed assessments of metacognition and affect recognition were stable across measurements points. Metacognition was related to concurrent assessments of positive, negative and disorganized symptoms. Multiple regressions revealed metacognition was related to prospective assessments of negative symptoms after controlling for baseline negative symptoms and executive function.

CONCLUSIONS

Metacognitive deficits are a stable feature of schizophrenia related with negative symptoms.

Schizophrenia and alterations in the experience of self and agency: Comparisons of dialogical and phenomenological views

Contemporary researchers have tended to present dysfunction in schizophrenia as the result of biological and social forces. While this has greatly advanced our knowledge, we are still without a full account of the illness’s first-person dimensions. A richer first-person account explains that schizophrenia is a disorder that interrupts the lives of people who must continue to struggle to find and create security and meaning. A range of literature has explored in many directions how schizophrenia is linked to profound changes in self-experience; however, there have not been systematic explorations of the ways in which these views converge and diverge. In response we will explore two different models of the processes which underlie a particular self-experience linked with schizophrenia: experiences of diminished agency. We will present a dialogical model of disturbances in agency and then compare and contrast it with another prominent philosophically based model, one from phenomenology.

Development of personal narratives as a mediator of the impact of deficits in social cognition and social withdrawal on negative symptoms in schizophrenia

Although negative symptoms are a barrier to recovery from schizophrenia, little is understood about the psychological processes that reinforce and sustain them. To explore this issue, this study used structural equation modeling to test whether the impact of social withdrawal and emotion recognition deficits upon negative symptoms is mediated by the richness or poverty of personal narratives. The participants were 99 adults with schizophrenia spectrum disorders. Social cognition was assessed using the Bell-Lysaker Emotional Recognition Task; social withdrawal, using the Quality of Life Scale; narrative coherence, using the Scale To Assess Narrative Development; and negative symptoms, using the Positive and Negative Syndrome Scale. The findings reveal that although social cognition deficits and social withdrawal are significantly associated with negative symptom severity, these relationships become nonsignificant when personal narrative integrity is examined as a mediating factor. These results indicate that the development of personal narratives may be directly linked to the severity of negative symptoms; this construct may be a useful target for future interventions.

The other self: psychopathology and literature

The figure of the "double" or the other self is an important topic in the history of literature. Many centuries before Jean Paul Richter coined the term, "doppelgänger," at the beginning of the Romantic Movement in the year 1796, it is possible to find the figure of the double in myths and legends. The issue of the double emphaszses the contradictory character of the human being and invokes a sinister dimension of the psychological world, what has been called in German as "umheimlich." However, does multiciplicity always involve pathology? Related to this figure in literary history, a new perspective from clinical psychology called "dialogical self" defines the self as a multi-voice reality. Along the same line, postmodernist psychology considers the self a discursive construction. From these perspectives, the "self" is situated a long way away from the classical essential conception of the self. In this paper, we review briefly some important landmarks of the figure of the double in the literature, and we compare the coincidences of the "double" experiencies described in literature with the experiences of our patients. Finally, we discuss how this literary tradition can help us to understand new psychological perspectives.

Metacognition in schizophrenia: correlates and stability of deficits in theory of mind and self-reflectivity

Research suggests that many with schizophrenia experience a range of deficits in metacognition including difficulties recognizing the emotions and intentions of others as well as reflecting upon and questioning their own thinking. Unclear, however, is the extent to which these deficits are stable over time, how closely related they are to one another and whether their associations with core aspects of the disorder such as disorganization symptoms are stable over time. To explore this issue, we administered three assessments of Theory of Mind (ToM), the Beck Cognitive Insight Scale (BCIS), and the Positive and Negative Syndrome Scale at baseline and 6 months to 36 participants with schizophrenia. Correlations revealed the ToM and BCIS scores were stable across the two test administrations and that the ToM tests were closely linked to each other but not to the BCIS. Poorer baseline performance on the ToM tests and the Self-Certainty scale of the BCIS were linked to greater cognitive symptoms at baseline and follow-up, while greater Self-Reflectivity on the BCIS was linked to greater levels of emotional distress at both baseline and 6-month follow-up. Results are consistent with assertions that deficits in metacognition are a stable feature of schizophrenia.

Schizophrenia and the progression of emotional expression in relation to others

Gaining an improved understanding of people diagnosed with schizophrenia has the potential to influence priorities for therapy. Psychosis is commonly understood through the perspective of the medical model. However, the experience of social context surrounding psychosis is not well understood. In this research project we used a phenomenological methodology with a longitudinal design to interview 7 participants across a 12-month period to understand the social experiences surrounding psychosis. Eleven themes were explicated and divided into two phases of the illness experience: (a) transition into emotional shutdown included the experiences of not being acknowledged, relational confusion, not being expressive, detachment, reliving the past, and having no sense of direction; and (b) recovery from emotional shutdown included the experiences of being acknowledged, expression, resolution, independence, and a sense of direction. The experiential themes provide clinicians with new insights to better assess vulnerability, and have the potential to inform goals for therapy.

Metacognition and social function in schizophrenia: associations of mastery with functional skills competence

Research has suggested that many with schizophrenia experience deficits in the ability to form complex ideas about their own mental states and those of others and to use that in the service of responding to the challenges of both everyday life and the illness itself. Preliminary evidence suggests that deficits in such metacognitive and social cognitive functions are a predictor of function independent of other aspects of schizophrenia. In this study, we explored whether the domain of metacognition that reflects the ability to form knowledge about one's own mental states and those of others and to use that knowledge to respond to psychological challenges, known as Mastery, was related to performance on a test of functional skills competence. Participants were 40 adults with schizophrenia spectrum disorders in a non-acute phase of illness. Metacognitive Mastery was assessed using the Metacognitive Assessment Scale (MAS) and skills competence was assessed using the UCSD Performance-Based Skills Assessment Battery (UPSA). Symptoms were also assessed using the Positive and Negative Syndrome Scale and executive function was assessed with the Wisconsin Card Sorting Test. Correlations revealed a significant relationship between Mastery and the UPSA comprehension/planning subscale. This relationship persisted even after controlling for symptoms and executive function in a regression analysis. Results are consistent with the possibility that the ability to use metacognitive knowledge to respond to daily life is uniquely linked with certain forms of functional competence among persons with schizophrenia, independent of the effects of illness severity.

Metacognition and social function in schizophrenia: associations over a period of five months

INTRODUCTION

Deficits in the ability to think about thinking have been widely observed in persons with schizophrenia and linked with concurrent assessments of various forms of function. Less is known though about their links to outcome over time. To address this issue, the current study explores whether Mastery, a domain of metacognition that reflects the ability to use knowledge about one's own mental states and those of others to respond to psychological challenges, is related to the frequency of social contact and persons' capacity for social relatedness.

METHODS

Participants were 72 adults with schizophrenia spectrum disorders enrolled in vocational rehabilitation; these patients completed a baseline assessment as well as a follow-up assessment 5 months later. Mastery was assessed using the Metacognitive Assessment Scale and social functioning by the Quality of Life Scale.

RESULTS

Using structural equation modelling, the proposed model demonstrated acceptable fit even when a range of possible confounding variables were entered as covariates.

CONCLUSIONS

. Results are consistent with the possibility that certain forms of metacognition affect social function among persons with schizophrenia, both concurrently and over time.

Metacognition in schizophrenia: the relationship of mastery to coping, insight, self-esteem, social anxiety, and various facets of neurocognition

OBJECTIVES. Deficits in metacognition, or the ability to think about thinking, are common in schizophrenia and associated with functional impairment. Unknown are what elements of function are affected by what aspects of metacognition. DESIGN. This study explored whether participants with differing capacities for Mastery, a domain of metacognition that reflects the ability to use knowledge about mental states to respond to psychological challenges, had difficulties in different elements of daily function. METHODS. Participants were 98 adults with schizophrenia or schizoaffective disorder in a non-acute phase, classified into three groups on the basis of ratings of their capacity for metacognitive Mastery using the Metacognitive Assessment Scale: low Mastery (those unable to plausibly represent psychological challenges), Intermediate Mastery (those able to plausibly represent psychological problems but cope primarily through passive measures or avoidance), and high Mastery (those able to cope with plausible problems through cognitive means). Participants completed assessments of coping preference, insight, self-esteem, and anxiety. RESULTS. Multivariate Analysis of Variance (MANOVA) and Analysis of Variance (ANOVA) revealed that the high-Mastery group had a greater preference for coping with stressors by thinking and talking about them, and greater insight than all other groups, and higher levels of feeling accepted by peers than the intermediate-Mastery group. The intermediate-Mastery group reported higher levels of resignation when facing stressors and more social phobia than the other two groups. These findings of Mastery group differences in self-esteem and anxiety persisted when neurocognition was controlled for in an Analysis of Covariance (ANCOVA). CONCLUSIONS. Mastery appears linked to coping preference, insight, self-esteem, and anxiety in a generally non-linear manner.

Conversations between carers and people with schizophrenia: a qualitative analysis using leximancer

We examined conversations between people with schizophrenia (PwS) and family or professional carers with whom they interacted frequently. We allocated PwS to one of two communication profiles: Low-activity communicators talked much less than their conversational partners, whereas high-activity communicators talked much more. We used Leximancer text analytics software to analyze the conversations. We found that carers used different strategies to accommodate to the PwS's behavior, depending on the PwS's communication profile and their relationship. These findings indicate that optimal communication strategies depend on the PwS's conversational tendencies and the relationship context. They also suggest new opportunities for qualitative assessment via intelligent text analytics technologies.

Personal narratives and recovery from schizophrenia

It has been recently argued that recovery from schizophrenia may involve the recapturing or developing one's personal narrative. Unknown is whether the fullness of the narrative accounts of persons with schizophrenia form about their lives is indeed uniquely linked to wellness in daily life, that is, independent of other factors including symptoms, hope, self-esteem and general intellectual functioning. To explore this issue the current study correlated assessments of personal narratives using the Scale to Assess Narrative Development with the Quality of Life Scale for 103 adults with schizophrenia spectrum disorders. General assessments of personal narrative were associated with the quality and quantity of social relationships, even after controlling for positive and negative symptoms, self report of hope and self-esteem and a test of general intellectual function. The domains of social connectedness within narratives were most closely linked with frequency of social relationships and the domains of Agency and Social Worth were mostly closely linked with quality of social relationships after the effects of symptoms, hope, self-esteem and general intellectual function were accounted for statistically.