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Can A Person Diagnosed With Schizophrenia Construct A Valid Narrative About Their Experiences

Level 3 clinical submission

Date : 08/01/2016

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Emily

Uploaded by : Emily
Uploaded on : 08/01/2016
Subject : Psychology

Consider whether a person diagnosed with schizophrenia can construct a valid narrative about their experiences


Being diagnosed with schizophrenia is often associated with neurological and cognitive disturbances which compromise the ability to express a recognizable narrative (Plagnol, Pachoud, Claudel & Granger, 1996). In the past this has led to clinicians not understanding the discourse of such patients and therefore not giving any importance to their experiences. Through the work of antipsychiatrists such as Laing, Cooper and Szasz the importance of narrative in helping to understand patient recovery and treatment for such individuals has grown. Although, this has left some argument as to whether persons diagnosed with schizophrenia can construct a valid narrative about their experiences. The aims of this essay are fourfold. First to challenge the notion of what is necessary for a narrative to be valid and to see how this ostracises the narratives of those with schizophrenia secondly how the beliefs and experiences of those working with such clients influences the validity of such narratives thirdly how altering the way narratives of those with schizophrenia should be looked at as not to discredit their validity fourthly ethical considerations for narrative therapy and how narrative therapy may be used to improve further investigation into the experiences of people diagnosed with schizophrenia. By looking at these topics this essay shall argue that people diagnosed with schizophrenia are able to construct a valid narrative of their experiences in a way that is meaningful to their own individual experiences but lack the ability to express this in a way that is deemed valid by clinicians.

Perhaps one of the most important aspects concerning the narrative of schizophrenic patients is how certain beliefs about what constitutes a narrative to be valid ostracises the uniqueness of narratives constructed by those with schizophrenia. Often those with schizophrenia have difficulties in maintaining a consistent use of language (Sarbin, 1998, as cited in Rivera & Sarbin, 1998). Such patients often show a poverty of speech, poverty of content of speech, give irrelevant replies to questions, derail from the topic, are incoherent, seem illogical and lack self-reference (Frith, 1992a). All of which contribute to problems in understanding such patients and has lead to the some such as Stone (2004, as cited in Frith, 1992b) to suggest that any narrative of experiences are simply fragmented dissociative thoughts which lack “Linearity, wholeness and coherence” (2004, as cited in Frith, 1992, p. 33) and are therefore “anti narrational in character” (2004, as cited in Frith, 1992, p. 17). The medical model also appears to support such beliefs. This model is built around the Western emphasis on linearity of past, present and future which must be expressed coherently and with reason in order to be understood and deemed valid by others (Torn, 2011a). This emphasis in linearity is important in the construction of a constitutional narrative (Baldwin, 2005a). Often if a patient such as those with schizophrenia describes an experience in a way that does not appear to follow such structure (which is common) then these narratives will be seen as symptoms of the illness and seen as invalid it is as if the narrative then becomes the illness (Laing, 1990a). Despite the apparent uniqueness in the cognition of patients with schizophrenia and their use of language, their narratives of experiences continue to be compared to coherent narratives and are therefore seen as inadequate or not recognised as narratives at all (Baldwin, 2005b) also known as ‘narrative impoverishment’ (Lysaker & Lysaker, 2006). Not being able to articulate experiences in a conventionally coherent manner does not mean that they should be ignored. Various studies have found that patients often share common threads in their experiences, they appear to show a meaningful sense of self and social identity and many are able to explain why they think their delusions or hallucinations started (Carless, 2008 Meissner, 1981 Koivisto, Janhonen & Vaisanen, 2003). They are also able to describe their unique individual experiences and how events in their lives may have lead to their mental health problems showing a clear understanding of past, present and future (Crossley & Crossley, 2001a). Therefore suggesting that those with schizophrenia are impaired only in their ability to communicate with others in a way that meets the rigid structure necessary for a constitutional narrative or a narrative deemed valid by the medical model. As to avoid ostracising the complex narratives such as those with schizophrenia they should not be associated with a loss of narrative but instead a narrative which is not easily accessible by others due to the current inflexible views held by some as to what constitutes a valid narrative.

Another way in which the validity of the narratives of patients with schizophrenia is undermined is through the experiences and beliefs of the listener and how this shapes their interpretation of schizophrenic narratives. Such experiences can only truly be understood by not judging the patient through ones own experiences and understandings (Lysaker & Buck, 2006). It is important that “we have to recognise all the time his distinctiveness and differentness, his separateness and loneliness and despair” (Laing, 1990, p. 38). Some argue that In order for a narrative to be understood and to make better sense of a narrator’s experiences the listener must share similar cultural conventions with the narrator and must be able to relate to the narrators experiences (Bruner, 2004). This narrator-listener relationship is made difficult as schizophrenic experiences may sometimes come across as so extreme and different to that of the listener that the experiences seem to be un-understandable (Pienkos & Sass, 2012a). Similarly this lack of understanding strengthens this view of ‘sane’ (clinician) and ‘insane’ (patient) which contributes to the depersonalisation and objectification which compromises the validity of the patient’s narrative (Crossley & Crossley, 2001b). The clinician must make an attempt to understand the metaphors in terms of their social, historical and cultural context which underlie patient narratives of their experiences (Thomas & Bracken, 2004) and accept the reality of the patients experiences (Pienkos & Sass, 2012b). This is known as representational narrative as it looks at how the individual interprets their experiences in relation to the world (Avdi, & Georgaca, 2007). By constructing a representational narrative and by altering how the clinician approaches dialogue with the patient in this way it seems that the narrative of those with schizophrenia may be understood within the context of the individual’s experiences (Gruber & Kring, 2008). And thus it appears that the patient’s problem with an incoherent narrative and lack of language structure is the listener’s problem in understanding the speech rather than the individual with schizophrenia (Frith, 1992c). Therefore in order to avoid such issues and to improve validity tools must be put in place in an attempt to bridge the gap between the clinicians beliefs and experiences and the patients.

Phenomenology helps to explore the differences between the patient and listeners experiences in order to understand and validate the narrative of such experiences. Sarbin & Allen (1968, as cited in Sarbin, 1998) hold the belief that what patients are describing in their experiences are ‘as if’ behaviours.

“When people claim their imaginings are real they are probably deeply involved in ‘as if’ behaviour, behaviour that may be described as being lively, forceful & vivid – words that connote the bodily effects of emotional life’’ (Sarbin, 1998, as cited in Rivera & Sarbin, 1998, p. 26).


This is the idea that the patient is trying to find ways to express the very powerful emotions that they are feeling and in order to convey these to the listener with as much power, they lose the ‘it is as if’ and express the experience in a literal sense (Rhodes & Jakes, 2004). It is important for clinicians when examining the narrative framework of delusions to assign these experiences with meanings relevant to the individuals own experiences (Davidson, 1993 Baldwin, 2005c). One way of doing this is through chronotope analysis which is an analytic narrative tool which considers history and culture and how these are represented through the metaphors used by such patients when explaining their experiences (Bakhitin, 1981, as cited in Torn, 2011). This makes the meaning of the experiences much clearer for patient and clinician and looks at the development of schizophrenia through past, present and future in order to validate the experiences and help in recovery (Torn, 2011b). Phenomenology is the study of the structure of experiences and may be used to extract the meaning of such experiences from individual’s dialogue into a narrative which can be easily understood by the listener (Raballo, 2011). Heidegger phenomenology makes it possible to look at how the world makes sense to the individual by looking at their experiences within the context that they occur (Bracken & Thomas, 2001a). Hermenuetic phenomenology is an extension of this and has been used to investigate how meanings are shown through language and how the narrative shows the meaning the individual attaches to themselves and their identity (Bracken & Thomas, 2001b). Both aim to look at the meaningful reality of the patients distress in which they attempt to express in the metaphors that appear in their narratives metaphors that otherwise would be ignored (Maher, 1974, as cited in Frith, 1992). Considering the difficulties in cognition and language that those with schizophrenia appear to have, Laing, Cooper & Szass (Baldwin, 2005d) suggest that it is important to loosen the rigid narrative formulations that the medical model would suggest is necessary for a valid narrative. It has been useful to combine short narratives which do not rely on coherent and chronological stories over time and is not concerned with coherency and consistency (Baldwin, 2005e). It is therefore important to lose the idea that narratives need to be chronological and to focus on meaning rather than time. Adjusting how such narratives are interpreted through the use of such tools and by making modifications to the rigidity of narrative is important in order to look at the narrative of those with schizophrenia as not to discredit their validity.

There are also ethical implications which are attached to the study of narrative in people such as those diagnosed as having schizophrenia. The medical model approach to narrative assumes the belief that those diagnosed with schizophrenia are faulty in some way as they can not construct a coherent narrative of their experiences and are therefore unable to construct a sense of self and identity (Beecher, 2009). An endurance narrative emphasises the psychosis as a disability to the individual and their experiences as management of an ongoing condition which is deemed incurable (Thornhill, Clare & May, 2004a). Through the use of phenomenology, looking at short stories of experiences and through chronotope analysis as mentioned above, it is possible to see that those diagnosed with schizophrenia are able to construct a valid self and identity even when narrative appears to be damaged (Mehan & Machachlan, 2008). However simply investigating narrative assumes a power between individuals diagnosed with schizophrenia and the clinician. A distinction is made by the clinician as to what is right and wrong, real or imaginary and normal or psychotic about their experiences and dialogue and as such may be controlled and constructed through narrative therapy (Pienkos & Sass, 2012c). Although investigating narrative helps to bind the listener and teller it also encourages approaching such clients with an aim of construction and treatment (Baldwin, 2005f). Treatments such as cognitive behavioural therapy (CBT) for psychosis involves challenging the individuals delusions and ignores the present day meaning for the patients delusions and hallucinations which are deemed valid and real to the patient (Pienkos & Sass, 2012d). Narrative treatments aim to change incoherent and chaotic narratives into coherent ones and form a structure which meets the researcher’s or clinician’s views of the patients past, present and future (Torn, 2011c). Where the individual may feel they need a chance to be listened to in order to develop as a person, treatment such as this which encourages an identity as a chronic patient can be more damaging than helpful (Thornhill, Clare & May, 2004b). This approach to narrative assumes that schizophrenia is a real condition that can be recovered from (France & Uhlin, 2006) and suggests that the individuals should adjust how they view the world into a way that is ‘normal’ by the clinicians standards (Van Dongen, 2003). Although, the investigation into narrative must not be viewed the same as narrative therapy, as research into narrative has helped to validate those experiences and help identify important aspects in the treatment of those diagnosed with schizophrenia.

Therefore this suggests that people with schizophrenia are not able to construct a recognizable and coherent narrative about their experiences in a way that makes them readily available and understood by clinicians but that their narratives of experiences are valid none the less. It appears that in order to do this several things must be done the listener must construct the narrative as the individuals representation of the world the listener must attempt to put their own experiences and beliefs aside they must listen to the individual and interpret the individuals experiences as real and meaningful whilst bearing in mind the power that such research gives to the listener and consider the implications of labelling the experiences as being different from the ‘norm’. It seems that there is a need to reframe the understanding of what an acceptable narrative is in order to include the differences and abnormalities found in those with severe mental health issues such as schizophrenia. This is important for clinicians in enabling them to study the experiences of those with schizophrenia in order to facilitate the way such individuals are treated and cared for. Approaching narratives as valid is vital in gaining more information into development and recovery which is not made available by a diagnosis. It also helps to prevent interpreting all behaviours as symptoms of schizophrenia and helps to look at the differences between individuals diagnosed with the same disorder to prevent misdiagnosis. “Key to developing an enabling understanding of madness is to see the experiences in question as both valid and meaningful” (Thomas & Leudar, 1996, p. 26).




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