Insight in schizophrenia: Structure and justification of sufferer's illness narratives

Over the last decade, much of the literature on insight in schizophrenia has reflected a biomedical viewpoint whereby insight is represented as a multidimensional entity. Such an observer-privileged perspective stands at odds with positions which also validate a sufferer's meaning-centered illness beliefs. The general aims of the thesis are to investigate the merit of this latter understanding, and consider its usefulness for case management. A pilot study involving twenty two participants was undertaken to (a) examine the dimensionality of an insight questionnaire, (b) examine the structure of illness belief narratives given by participants deemed to be insightful or non-insightful, and (c) provide a qualitative commentary on illness experiences. No underlying dimensional structure of insight was found, and a series of analyses failed to find narrative event differences in the illness stories given by the insight groups. The qualitative commentary suggested that lived experiences are of particular significance to a sufferer and also ground his or her self-representation. These findings suggested, firstly, the lack of relevance of a biomedical construct for a sufferer's self-report, and secondly, the importance of a higher-order appraisal to investigate adequately a sufferer's illness accounts. In response, Experiment Two adopted a hermeneutic analysis, incorporating a structural and a poetics level of evaluation, to investigate the illness explanations of twenty four participants across three time points. The analysis focused specifically on "complexity", "emphasis, and "adjustment" evaluations at a discourse structure level, and conversely, at a poetics level, upon illness and self-representations signified in "turning-point" experiences. The results supported the predictions that (a) sufferers place greater importance upon "everyday" understandings of symptomatic experiences in comparison to their biomedical knowledge and, moreover, (b) turning-points play a pivotal role in framing everyday illness appreciations. A model integrating narrative explanations and the dual cognitive processes thought to underlie insight-awareness of change and judgement of morbidity-is proposed. It is argued that this conceptualisation provides new possibilities for case management practice.