| | Associations of metacognition and internalized stigma with quantitative assessments of self-experience in narratives of schizophreniaReceived 26 January 2007; received in revised form 20 April 2007; accepted 27 April 2007. Abstract Observations that diminishment of self-experience is commonly observed in schizophrenia have led to the suggestion that the deepening of self-experience may be an important domain of recovery. In this study we examined whether internalized stigma and deficits in metacognition are possible barriers to the development of richer self-experience. Narratives of self and illness were obtained using a semi-structured interview from 51 persons with schizophrenia spectrum disorder before entry into a rehabilitation research program. The quality of self-experience within those narratives was rated using the Scale to Assess Narrative Development (STAND). These scores were then correlated with concurrent assessments of stigma using the Internalized Stigma of Mental Illness Scale (ISMIS) and metacognition using the Metacognition Assessment Scale (MAS). A stepwise multiple regression controlling for age, social desirability and awareness of illness revealed that higher STAND ratings were significantly associated with greater ratings of metacognitive capacity and lesser ratings of stereotype endorsement. Results suggest that qualities of self-experience expressed within personal narratives of schizophrenia may be affected by internalized stigma and deficits in the capacity to think about one's own thinking and the thinking of others. 1. Introduction  Evidence has steadily accumulated over the last 30 years that many people with schizophrenia spectrum disorders achieve partial or full recovery (Corrigan, 2003, Harding et al., 1992, Roe, 2001, Spaniol et al., 2002, Whitehorn et al., 2002). Resnick and colleagues (2004) have proposed that such recovery consists of changes in at least two different domains: an objective domain that involves the absence of features of illness (e.g. symptoms) and a subjective one that involves satisfaction with one's life and a hopeful sense of the future. 1.1. Sense of self and recovery from schizophrenia Recently we have suggested that, for many, the subjective domain of recovery may also include changes in the quality of how persons experience themselves, that is, in the degree to which they coherently and meaningfully experience themselves as unique individuals with a sense of purpose and value (Lysaker et al., 2006a, Lysaker et al., 2006b, Lysaker and Buck, 2006). From many perspectives, schizophrenia has been linked to a diminished sense of oneself as a being in the world (Bleuler, 1911/1950, Roe and Ben-Yishai, 1999, Jacobson, 2002, Davidson, 2003, Stenghellini, 2004). Schizophrenia has been associated, for instance, with difficulties constructing a coherent narrative of one's life, one that links the past and present (Holma and Aaltonen, 1997, Young and Ensign, 1999, Lysaker and Lysaker, 2002, Gallagher, 2003) and portrays meaningful connections between oneself and others (Lysaker et al., 2003c, Roe et al., 2004, Horowitz, 2006). Thus, if being ill entails having an impoverished sense of oneself, we have suggested that becoming well may require a person to recapture a fuller sense of who he or she is in the world. This seems consistent with observations that with mastery of life tasks, sense of self may deepen (Bebout and Harris, 1995, Davidson, 2003) and that an enriched sense of self may pave the way for taking needed action (Roe, 2001, Lysaker et al., 2003b). If self-experience is a crucial domain of recovery, however, it may be important to understand the phenomena that affect it. What forces contribute to and sustain a diminished sense of self in schizophrenia? What are the concrete barriers to recovery in this domain? An understanding of what sustains or diminishes self-experience could have critical implications for models of wellness as well as for developing treatments. 1.2. Two factors that may contribute to diminished self-experience in schizophrenia To date, two different literatures have pointed to phenomena linked to schizophrenia that could affect self-experience: the internalization of stigmatized beliefs about mental illness and the capacity for metacognition. Stigma refers to negative stereotypic beliefs about mental illness and internalized stigma refers to the acceptance of those beliefs. Internalized stigma has been linked to lower self-esteem and depressed mood among persons with severe mental illness and, moreover, has been suggested to lead persons to view themselves as possessing lesser social value (Markowitz, 1998, Wright et al., 2000, Ritsher and Phelan, 2004). According to one view, as persons accept stigma, their identity is engulfed by their illness and they experience themselves as being fundamentally diminished (Lally, 1989). Metacognition refers to the capacity to think about one's own thinking, for example, to the ability to name and scrutinize one's thoughts and feelings about oneself and about others. Research has suggested that this capacity is compromised in schizophrenia and may be a primary source of psychosocial impairment (Langdon et al., 2001, Koren et al., 2006). With lesser abilities to think about oneself and others, persons may experience themselves as increasingly less of an actor in their own lives (Lysaker et al., 2005a, Lysaker et al., 2005b, Lysaker et al., 2005c). While it seems a matter of intuition that stigma and metacognitive deficits may interact in a vicious cycle to diminish persons' experiences of themselves, we are aware of little research that has explored their mutual or joint contributions to diminished self-expereince in schizophrenia. Perhaps one barrier to addressing this question has been that most research to date on self-experience in schizophrenia has been qualitative and not easily correlated with quantitative measures of cognition or stigma. To complement this qualitative literature in the study of self-experience in schizophrenia, we have used a narrative theory of self (Gallagher, 2000) to develop a semi-structured interview to elicit a narrative of self-experience (the Indiana Psychiatric Illness Interview (IPII) Lysaker et al., 2002) and a scale to quantitatively assess self-experience as expressed within those narratives: the Scale to Assess Narrative Development (STAND) (Lysaker et al., 2003a). 1.3. Study aims In the current study we have sought to examine the correlates of self-experience in schizophrenia by correlating self-experience as assessed by the STAND with measures of metacognition and internalized stigma. To rule out the potentially confounding effects of unawareness of illness, verbal ability and the tendency to present oneself in a socially positive light, we also included measures of these constructs. We predicted that greater metacognitive capacity and lesser internalization of stigma would independently predict higher scores on the STAND even when possible confounds such as awareness of illness and social desirability were statistically controlled. Of note, given that metacognitive capacity and the internalization of stigma are theoretically unrelated constructs, we did not anticipate that they would be correlated with one another. We secondarily planned exploratory correlations to examine the associations of individual elements of metacognition and subscales of the STAND to generate hypotheses for future research. 2. Methods 2.2. Instruments 2.2.1. Scale to Assess Unawareness of Mental Disorder (SUMD; Amador et al., 1994) The SUMD is a rating scale completed by clinically trained research staff following a semi-structured interview and chart review. For the purposes of this study, we used the sum of the three central items of the SUMD: (a) awareness of mental disorder; (b) awareness of the consequences of mental disorder; and (c) awareness of the effects of medication. Each of these items is rated on a five-point scale that ranges from “1” (complete awareness) to “5” (severe unawareness). The total score can accordingly range from 3 to 15. Assessment of interrater reliability for raters in this study was in the good to excellent range (intraclass r =0.90). 2.2.2. The Vocabulary subtest (VS; Wechsler, 1997) The VS is a subtest of the WAIS III that assesses participants' knowledge of vocabulary by presenting words for participants to define in increasing order of difficulty. This subtest has been widely used to assess global verbal intellectual function. Age-corrected scaled scores are generated with the expected population mean being 10. 2.2.3. Internalized Stigma of Mental Illness Scale (ISMIS; Ritsher et al., 2003) The ISMIS is a 29-item paper-and-pencil questionnaire designed to assess the subjective experience of stigma. It presents participants with first person statements and asks them to rate on a four-point Likert scale whether they “Strongly disagree, “Disagree,” “Agree” or “Strongly agree” with statements related to having a mental illness. Items are summed to provide several different scale scores. For the purposes of this study, we were concerned with the first three of these: Alienation, which reflects feeling devalued as a member of society; Stereotype Endorsement, which reflects agreement with negative stereotypes of mental illness; and Discrimination Experience, which reflects current mistreatment attributed to the biases of others. The final two scales were not considered as they were not thought likely to be directly linked to narrative: Social Withdrawal, which reflects avoidance, and Stigma Resistance, which asks about participants' perceived active deflection of stigma. All scale scores are calculated as averages with higher scores suggesting graver experiences of stigma. Evidence for acceptable internal consistency, test–retest reliability, factorial and convergent validity has been reported along with correlations with morale and well-being (Ritsher et al., 2003, Ritsher and Phelan, 2004). 2.2.4. Marlowe-Crowne Social Desirability Scale (MCSDS; Crowne and Marlowe, 1960) The MCSDS is a self-report measure of 33 items that participants are asked to endorse as true or false regarding their own experiences. Items reflect culturally sanctioned behaviors that are nevertheless unlikely to occur. Higher scores suggest a need to obtain approval by responding in the perceived culturally approved manner. 2.2.5. Indiana Psychiatric Illness Interview (IPII; Lysaker et al., 2002) The IPII is a semi-structured interview developed to elicit illness narratives. A research assistant conducts the interview, which typically lasts between 30 and 60 minutes. Responses are audiotaped and later transcribed. The interview is divided conceptually into four sections. First, rapport is established and participants are asked to tell the story of their lives in as much detail as they can. Second, participants are asked if they think they have a mental illness and how they understand it. This is followed with a question about what has and has not been affected by their condition. In the third section participants are asked whether and, if so, how their condition “controls” their life and how they “control” their condition. Fourth, participants are asked what they expect to stay the same and what will be different in the future, again in terms of interpersonal and psychological function. This measure differs from other psychiatric interviews in that it does not introduce specific symptoms (e.g. hallucinations) or reactions to treatment for the participant to discuss. The interviewer may ask for clarification when confused and may query non-directively, as the task is to elicit enough information to understand the story a participant is telling, but not to assess symptom severity. The IPII thus results in a narrative of self and illness that can be analyzed in terms of the larger story being told and not merely the presence or absence of specific beliefs. 2.2.6. Scale to Assess Narrative Development (STAND; Lysaker et al., 2003b) The STAND was designed to assess four key aspects of recovery as they might emerge in client narratives. It is composed of four subscales: Social Worth, Social Alienation, Personal Agency and Illness Conception, each rated on a five-point Likert scale. Social Worth assesses the extent to which persons experience themselves as valuable to others and society. Social Alienation refers to the extent to which persons experience intimate connections to others in their families or communities. Personal Agency assesses the degree to which persons experience themselves as able to affect events in their own lives. Lastly, Illness Conception assesses the extent to which persons experience and can account coherently for aspects of their disorder. Subscale scores range from one to five; summing all four subscale scores derives the STAND total score, which can therefore range from 4 to 20. The anchors for each subscale have been presented elsewhere (Lysaker et al., 2003b), along with evidence of an acceptable degree of internal consistency (coefficient alpha=0.86) and interrater reliability for the total score (intraclass correlation=0.87). Earlier studies with a different sample demonstrated that persons with schizophrenia produced significantly more impoverished narratives than participants with other disabilities, such as major depression without psychosis or legal blindness (Lysaker et al., 2005c) and that ratings on the STAND were significantly related to other measures of recovery including hope, quality of life and the absence of significant symptoms (Lysaker et al., 2006a). Overall scores for the current sample demonstrated a significant degree of internal consistency (Cronbach's alpha=0.76, P<0.01). Interrater reliability in this study was obtained by having the rater rate transcripts from a previous sample along with two other trained raters (intraclass correlation=0.88). 2.2.7. Metacognition Assessment Scale (MAS; Semerari et al., 2003) The MAS is a rating scale that assesses metacognitive abilities as manifest in an individual's verbalizations. It was created in Italian and translated into English. The MAS was originally designed to detect within psychotherapy transcripts changes in the ability of persons with severe personality disorders to analyze their own thinking (Semerari et al., 2005). The MAS focuses on metacognitive functions (i.e. ideas and beliefs linked to a particular mental phenomenon: beliefs about beliefs) and not on metacognitive contents. It conceptualizes metacognition as the set of abilities that allow persons to understand mental phenomena and to use that understanding to tackle tasks that are sources of distress. The MAS contains four scales: “Understanding of one's own mind” or the comprehension of one's own mental states; “Understanding of others' minds,” or the comprehension of other individuals' mental states; “Decentration” or the ability to see the world as existing with others having independent motives; and “Mastery” or the ability to work through one's representations and mental states, with a view to implement effective action strategies in order to accomplish cognitive tasks or cope with problematic mental states. The MAS asks the rater to indicate whether the participant has successfully used or failed to use a function for each task. For example, the rater must determine if the participant can identify different emotions they feel and recognize that their understanding of life events is subjective. In consultation with authors of the MAS, we have adapted this scale for the study of IPII transcripts (Lysaker et al., 2005a, Lysaker et al., 2005b) and awarded a “1” for the full presence of a function and a score of “0.5” for the partial presence of a function. Items of each scale are then summed to provide a total score for each scale. The highest score obtainable for “Understanding of one's own mind” is “9”, for “Understanding of others' minds,” an “8”, for “Decentration” a “3”, and for “Mastery” a “9”. Interrater reliability was assessed in this study with two blind raters for 10 transcripts. The MAS differs from the STAND conceptually in that it rates within persons' narratives the capacity to think about thinking in an increasingly complex manner rather than the presence or absence of specific themes, such as self as able to affect life events. In other words, persons could theoretically be able to think about their own thinking but not see themselves as having social worth or vice versa. Consistent with our earlier use with a different sample, good overall reliability was found with an intraclass correlation for the total score of 0.85 (P<0.05). Analyses revealed that subscales were internally consistent (Cronbach's alpha=0.79, P<0.01). 2.3. Procedures After written informed consent was obtained from participants, diagnoses were determined using the Structured Clinical Interview for DSM-IV (SCID) conducted by a clinical psychologist. Next, participants were given the ISMIS, SUMD, VS, MCSDS and IPII as part of a baseline assessment for a study of Cognitive Behavior Therapy and work outcome. The IPII and SUMD interviews were conducted by different personnel. The IPII interview was audiotaped and later transcribed with identifying information removed. Ratings of the transcripts were made using the STAND and MAS with two different raters blind to participant identity, one another's ratings, test performance, and insight ratings. Raters were not present during the SUMD or IPII interviews, nor did they transcribe the audiotapes of the interviews. Raters had a minimum of a graduate degree in psychology or nursing and were trained by the first author. A subset of these IPII transcripts (n=34) was previously rated for the STAND and the correlations with self-esteem and readiness for change have been reported elsewhere (Lysaker et al., 2006b). 2.4. Analyses Analyses were planned in five phases. First, we sought to determine if the STAND, MAS and ISMIS scores were linked with demographic variables including age, education, diagnosis, and hospitalization history. Second, univariate correlations were conducted to determine whether the STAND, MAS or ISMIS scores were linked with the variables identified as possible confounds: the SUMD, VS, and MCSDS scores. Third, univariate correlations were conducted to determine whether the STAND was associated with the MAS and ISMIS scores. Fourth, in the case that both the MAS and any of the ISMIS scores were linked with the STAND, a stepwise multiple regression was planned in which potential confounds would be forced to enter first as covariates and then MAS and ISMIS Stereotype Endorsement scores would be allowed to enter to predict the STAND total score. Finally, exploratory correlations were planned to examine associations between individual MAS and STAND subscale scores. All analyses were performed with SPSS 13 for Windows. 3. Results Table 1 presents the means and standard deviations of key scores. Analyses examining the relationship of the STAND, MAS and ISMIS scores with demographic information revealed that STAND scores were not significantly correlated with age, education, or lifetime number of hospitalizations. STAND, ISMIS and MAS scores did not differ between participants with schizophrenia and schizoaffective disorder. The MAS total was significantly related to education (r=0.27, P=0.048) but not age or hospitalization history. The ISMIS scores were not significantly related to age, education, or hospitalization history. | | |  | Score | Mean (S.D.) | Possible range | |
|---|
| STAND Illness Awareness | 3.26 (1.07) | 1–5 | | | STAND Alienation | 3.25 (1.29) | 1–5 | | | STAND Agency | 3.75 (1.18) | 1–5 | | | STAND Social Worth | 2.82 (1.17) | 1–5 | | | STAND Total | 13.08 (3.60) | 5–20 | | | MAS Awareness of ones' own mind | 4.10 (0.99) | 0–9 | | | MAS Awareness of others' minds | 3.22 (1.07) | 0–8 | | | MAS Decentration | 0.49 (0.78) | 0–3 | | | MAS Mastery | 3.47 (2.06) | 0–9 | | | MAS Total | 11.13 (4.19) | 0–29 | | | ISMIS Alienation | 2.49 (0.72) | 1–4 | | | ISMIS Stereotype Endorsement | 2.09 (0.54) | 1–4 | | | ISMIS Discrimination Experiences | 2.38 (0.54) | 1–4 | | | WAIS III vocabulary scaled score | 7.49 (3.46) | | | | Scale to Assess Awareness of Mental Disorder total | 7.76 (2.89) | 0–15 | | | MCSDS social desirability | 19.47 (6.23) | 0–33 | | | | |
Analyses comparing possible confounds, including SUMD, VS, or MCSDS with STAND, MAS and ISMIS scores, revealed that the Stereotype Endorsement score of the ISMIS was significantly related to the Social Desirability score (r=−0.33, P<0.05). The STAND and MAS totals were significantly related to the SUMD (r=−0.46, P<0.001; r=−0.38, P=0.006, respectively). No other significant relationships were observed. In the third phase of analyses, the STAND, MAS and ISMIS scores were correlated with one another. This revealed that the STAND total was significantly related to the Stereotype Endorsement score (r=−0.38, P<0.01) and the MAS total (r=0.59, P<0.001). The ISMIS Alienation and Discrimination Experience scores were not significantly correlated with the STAND total. The MAS total and the ISMIS were not found to be significantly correlated. Given that there were several significant univariate correlations between stigma and metacognition scores with the STAND total, a stepwise multiple regression was conducted. Given the links between social desirability and the ISMIS score, and between education and the MAS total, these scores were forced to enter in the first step in the equation as covariates. As the SUMD was linked to the STAND and MAS total, the SUMD total was forced to enter second also as a covariate. In the third step of the regression, the MAS total and ISMIS Stereotype Endorsement scores were allowed to enter in a stepwise manner to predict the STAND. Of note, because of the large number of variables involved alpha was set at the 0.01 level. As revealed in Table 2, even when controlling for social desirability, education and insight, these analyses revealed that greater MAS scores and lesser Stereotype Endorsement scores predicted higher STAND scores. Finally, for exploratory purposes, we correlated the subscales of the MAS and STAND (see Table 3). Again, given the number of comparisons, we used two-tailed tests despite the presence of directional hypotheses (e.g. lower MAS subscale scores should predict lower STAND subscale scores) and selected P<0.01 as the marker of significance rather than 0.05. | | | | STAND subscales | Understanding one's own mind | MAS subscales Understanding the others' minds | Decentration | Mastery | ISMIS Stereotype Endorsement | |
|---|
| Illness Awareness | 0.49 (0.0001) | 0.21 (0.14) | 0.19 (0.17) | 0.60 (0.0001) | −0.29 (0.05) | | | Alienation | 0.36 (0.01) | 0.42 (0.002) | 0.32 (0.02) | 0.44 (0.001) | −0.21 (0.14) | | | Agency | 0.28 (0.05) | 0.18 (0.20) | 0.27 (0.06) | 0.47 (0.001) | −0.31 (0.03) | | | Social Worth | 0.21 (0.14) | 0.38 (0.006) | 0.32 (0.02) | 0.39 (0.003) | −0.36 (0.009) | | | | |
4. Discussion While the quality of self-experience has been hypothesized to play an important role in recovery from schizophrenia, this is the first study we are aware of to examine the association of quantitative ratings of the qualities of self-experience with two phenomena that have been hypothesized to affect self-experience: stigma and metacognition. As predicted, higher levels of metacognition and less endorsement of stigma were linked with higher scores on our assessment of narrative self-experience. After we controlled for several possible confounds including education, social desirability and global awareness of illness, metacognition and internalized stigma continued to be related to the STAND total, together accounting for over one quarter of the variance, even after another quarter had already been accounted for by the three covariates. Results thus suggest that participants who demonstrated lesser abilities to think about their own thinking and the thinking of others, and who also endorsed negative stereotypes about mental illness, tended to tell more impoverished stories about themselves and the challenges posed by their mental illness. While the correlational nature of these results precludes drawing conclusions about causality, they may suggest hypotheses for continued study. For one, these findings are consistent with models which suggest that disability across major medical conditions is best explained by the interaction of medical, social and psychological forces. One interpretation of the data is that aberrant cortical processes that erode metacognitive capacity along with societal stereotypes of mental illness combine to form a barrier to the ongoing experience of a vital sense of self. The combination of a declining capacity to hold one's own thoughts up to scrutiny coupled with an internalized belief that mental illness means one is incompetent may result in a person's experiencing a state that Bleuler described as finding one's “own person as well as the external world… in a completely unclear manner so that the patient hardly knows how to orient himself either inwardly or outwardly.” (p. 143). Importantly, there are alternative hypotheses that cannot be ruled out. It is possible that diminishment in self-experience makes persons more vulnerable to internalizing stigma or to having decrements in metacognitive capacity. Perhaps as persons experience a declining sense of who they are, they are less motivated to think about their thoughts and feelings as well as the thoughts and feelings of others. It is also possible that factors not assessed in this study could account for the observed relationships. While this was largely an exploratory study, there were some surprising findings. Only one of the ISMIS subscales was linked to the STAND scores. The fact that scores reflecting discrimination experiences and social alienation were not linked to STAND scores may suggest that the experience of distance or rejection from others does not affect narrative. Given the relatively higher mean scores for both of these indices, it may also be that most participants experienced both high levels of discrimination experiences and social alienation, and thus there was not sufficient variation within this sample to detect any relationship with narrative. The exploratory correlations between the STAND, MAS subscales and the Stereotype Endorsement scale may also provide some speculations for future research. For example, it appears that the Mastery subscale, or the capacity to cast oneself as an actor solving problems, was most closely linked to the STAND subscales and was the only subscale linked to Agency. This may suggest that the evolution of one's story as an agent requires the ability to see oneself as a problem solver in the world. Awareness of the other's mind and Stereotype Endorsement were also linked to social worth, which may suggest that social worth is a matter of mastery, the ability to understand the thoughts and affects of others and the rejection of stigma. Lastly, Awareness of one's own mind was the only scale beyond Mastery that was linked to Illness Awareness. This may point to the possibility that mastering tasks, along with the ability to think about one's own thinking, contributes to a more vital sense of self. As noted, however, these analyses were exploratory and are meant to generate rather than confirm hypotheses, as other interpretations of these results are possible. It may, for instance, be that having a sense of greater social worth makes it easier to think about the thoughts and feelings of others or to not internalize stigma. 4.1. Clinical implications With replication across more studies, these findings may have clinical implications. For instance, it may be that interventions are necessary which do move beyond addressing insight as an educational matter and also target both stigma and the capacity to think about one's own thinking in the context of problem solving. Furthermore, the presence of lower social worth may call for interventions that enhance persons' abilities to think about themselves in the midst of problem solving, that is, to enhance their abilities to think about the feelings of others, and to challenge their conceptions of what their illness means. As illustrated in a recent case study (Lysaker et al., 2005b), repeated assessments of counseling transcripts using the STAND and MAS may also provide an empirical assessment of progress and bring to clinicians' attention areas they might want to inquire about further. 4.2. Limitations Finally, there are limitations to this study. Sample size was modest in relation to the number of comparisons made. Although we used more conservative two-tailed tests, and despite unidirectional hypotheses, risk of spurious findings was increased. Generalization of findings also is limited by homogenous sample composition. Participants were mostly males in their forties willing to enter rehabilitation. It may well be that a different relationship exists between metacognition, stigma and narratives in schizophrenia among females or among younger males with schizophrenia, or persons who decline treatment or who are working and not in need of vocational rehabilitation. 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Young and Ensign, 1999. 41.Young SL, Ensign DS. Exploring recovery from the perspective of persons with psychiatric disabilities. Psychiatric Rehabilitation Journal. 1999;22:219–231. a Department of Psychiatry, 116H, Roudebush VA Medical Center, 1481 West 10th St., Indianapolis, IN 46202, USA b Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA c Department of Psychology, Indiana University Purdue University at Indianapolis, Indianapolis, IN, USA d Department of Community Mental Health, University of Haifa, Haifa, Israel  Corresponding author. Department of Psychiatry, 116H, Roudebush VA Medical Center, 1481 West 10th St., Indianapolis, IN 46202, USA. Fax: +1 317 988 3578.
PII: S0165-1781(07)00147-3 doi:10.1016/j.psychres.2007.04.023 © 2007 Elsevier Ireland Ltd. All rights reserved. | |
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