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QUESTION: How do people who have been admitted to hospital for psychotic disorders experience their sense of self in relation to the course of their disorder?
4 hospital facilities in the Yale Department of Psychiatry, New Haven, Connecticut, USA.
43 patients who were 20–39 years of age (mean age 28 y, 58% men); were admitted to hospital for severe mental illness with psychotic features (DSM-III-R diagnoses; 51% schizophrenia, 30% schizoaffective disorder, and 19% major affective disorder with psychotic features); and had no evidence of organic brain disorder or severe alcohol or drug abuse.
Patients were interviewed using a semistructured format initially in the hospital and bimonthly after discharge. Interviews were audiotaped. Investigators composed a narrative summary of each interview, which was dictated and transcribed. Verbatim transcripts of the first interview for each participant after discharge and narrative summaries of all other interviews were organised, reviewed, and analysed by using open coding case analysis, axial coding, identifying changes, and creating a synthesis.
5 categories of coping by using narrative were identified. (1) Participants separated their healthy selves from their ill selves, and used their healthy selves to tell their stories and to cope with their illness. The participants talked about themselves as myself and myself when I am ill. (2) The selves were able to interact and were no longer separate, isolated subjects. The healthy self remained the subject and the illness became an object. The healthy self was able to assume the position of narrator and shape the person's story. (3) Participants were able to change the meaning of the illness for themselves. The relation between the self and the illness became more complex, and the relation was no longer one sided. The self recognised the illness as a force to be reckoned with and responded accordingly. Participants could negotiate with the illness to change the meaning it held for then and to find ways to coexist with the disorder. (4) The healthy self began to develop the ability to actively influence the process of the illness, not just the meaning. Participants used narrative to gain a sense of control over the illness and to become protagonists in their own stories. (5) Participants were able to integrate the changes in their lives and illness and the relations between them. They could use narrative to incorporate their various experiences into a coherent whole.
Five categories of coping were identified in people who had been admitted to hospital for psychotic disorders. Narratives helped people to distinguish between their healthy self and the illness and to integrate their sense of self with their illness.
Roe and Ben-Yishai have done an important qualitative study on the use of narratives by people with serious mental illness. The necessity of hearing people's perspectives of their illnesses, or their “stories,” has gained increasing acceptance in the literature.1, 2 Systematic examinations of those narratives, which this article provides, have not been found in the literature, however. Roe and Ben-Yishai have used the theory of narratology (the study of narratives originating in literature) to understand better the subtleties of the narratives they gathered. The application of knowledge from one field of enquiry to another sheds new light on the stories of people with serious mental illness.
A hallmark of good qualitative research is transparency of the data analysis process.3 Roe and Ben-Yishai have done just that by providing a detailed and understandable description of their process of analysis, which gives greater credence to their results and conclusions.
An enduring sense of self beyond the illness has been proposed as important in recovery for people with schizophrenia.4 The use of narratives may well be a strategy that will reinforce that sense of self. Although Roe and Ben-Yishai are careful to conclude that further research is needed to confirm their categories of storytelling, clinicians could use these as a framework for listening to their clients' stories. This may enable clinicians to hear beyond the obvious, and to hear what the client is saying about their ability to cope with the illness at that time.
This is a promising area of research that could help to illuminate the recovering process of people with serious mental illness.
Source of funding: not stated.
For correspondence: Dr D Roe, Bar Ilan University, School of Social Work, 52900 Ramat-Gan, Israel. Fax +972 3 5247228.
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