You are on page 1of 8

Available online at www.sciencedirect.

com

Psychiatry Research 157 (2008) 31 38


www.elsevier.com/locate/psychres

Associations of metacognition and internalized stigma with


quantitative assessments of self-experience in
narratives of schizophrenia
Paul H. Lysaker a,b,, Kelly D. Buck a , Amanda C. Taylor c , David Roe d
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
Received 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 selfexperience 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.
2007 Elsevier Ireland Ltd. All rights reserved.
Keywords: Schizophrenia; Recovery; Stigma; Narrative; Metacognition; Insight

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;
Corresponding author. Department of Psychiatry, 116H, Roudebush VA Medical Center, 1481 West 10th St., Indianapolis, IN 46202,
USA. Fax: +1 317 988 3578.
E-mail address: plysaker@iupui.edu (P.H. Lysaker).

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

0165-1781/$ - see front matter 2007 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.psychres.2007.04.023

32

P.H. Lysaker et al. / Psychiatry Research 157 (2008) 3138

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 and
Buck, 2006; Lysaker et al., 2006a,b). 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,b,c).
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 selfexperience 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 selfexperience (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.

P.H. Lysaker et al. / Psychiatry Research 157 (2008) 3138

2. Methods
2.1. Participants
Participants were 46 adult men and 5 women with
DSM-IV diagnoses of schizophrenia (n = 31) or schizoaffective disorder (n = 20) as confirmed by the
Structured Clinical Interview for DSM-IV (SCID).
The participants comprised the full sample of persons
enrolled in a larger study seeking to develop a
cognitive behavioral therapy targeting working function in schizophrenia. All were recruited from the
outpatient Psychiatry Service of a VA Medical Center
or Community Mental Health Center and were in a
post-acute phase of illness as defined by having no
hospitalizations or changes in medication or housing in
the month before entering the study. Excluded from the
study were participants with mental retardation or
active substance abuse. The mean age and education of
the sample were 48.49 (S.D. = 9.2) and 12.67 (S.D. =
2.6) years, respectively. Participants had, on average,
5.94 lifetime psychiatric hospitalizations (S.D. = 6.6)
with the first occurring on average at the age of 27.20
(S.D. = 9.9). Ethnic breakdown was as follows: Caucasian, n = 22; African-American, n = 28; and Latino,
n = 1.

33

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, testretest 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. 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.

2.2.4. 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

34

P.H. Lysaker et al. / Psychiatry Research 157 (2008) 3138

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 b 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,b) 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

P.H. Lysaker et al. / Psychiatry Research 157 (2008) 3138

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 b 0.05). Analyses revealed that subscales were
internally
consistent
(Cronbach's
alpha = 0.79,
P b 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).

35

dual 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.
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 b 0.05). The STAND
and MAS totals were significantly related to the SUMD
(r = 0.46, P b 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 b 0.01) and the MAS total (r = 0.59, P b 0.001). The
ISMIS Alienation and Discrimination Experience scores
were not significantly correlated with the STAND total.

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 indivi-

Table 1
Mean and standard deviations
Score

Mean (S.D.) Possible


range

STAND Illness Awareness


3.26 (1.07)
STAND Alienation
3.25 (1.29)
STAND Agency
3.75 (1.18)
STAND Social Worth
2.82 (1.17)
STAND Total
13.08 (3.60)
MAS Awareness of ones' own mind
4.10 (0.99)
MAS Awareness of others' minds
3.22 (1.07)
MAS Decentration
0.49 (0.78)
MAS Mastery
3.47 (2.06)
MAS Total
11.13 (4.19)
ISMIS Alienation
2.49 (0.72)
ISMIS Stereotype Endorsement
2.09 (0.54)
ISMIS Discrimination Experiences
2.38 (0.54)
WAIS III vocabulary scaled score
7.49 (3.46)
Scale to Assess Awareness of Mental 7.76 (2.89)
Disorder total
MCSDS social desirability
19.47 (6.23)

15
15
15
15
520
09
08
03
09
029
14
14
14
015
033

36

P.H. Lysaker et al. / Psychiatry Research 157 (2008) 3138

Table 2
Stepwise multiple regression predicting the Scale to Assess Narrative
Development total from measures of metacognition, insight and stigma
(n = 51)
Independent variables

Partial Model df
Ra
Ra

Education b
Social Desirability scale a
Scale to Assess Awareness
of Mental Disorders total b
Metacognition
assessment total c
Stereotyped Self-Stigma
scale c

0.06

0.06

(1,49)

3.04 0.09

0.19

0.25

(2,47)

6.28 0.004

0.16

0.41

(1,46) 12.92 0.001

0.11

0.52

(5,45) 10.02 0.003

Bolded values are statistically significant.


a
This variable was allowed to enter in a second step.
b
Both variables were forced to enter first.
c
These variables were allowed to enter stepwise in a third step.

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 b 0.01 as the
marker of significance rather than 0.05.
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

Table 3
Pearson correlations and their statistical significance comparing STAND subscales with the MAS subscales and ISMIS Stereotype Endorsement score
STAND
subscales

Understanding
one's own mind

MAS subscales
Understanding
the others' minds

Decentration

Mastery

ISMIS Stereotype
Endorsement

Illness Awareness
Alienation
Agency
Social Worth

0.49 (0.0001)
0.36 (0.01)
0.28 (0.05)
0.21 (0.14)

0.21 (0.14)
0.42 (0.002)
0.18 (0.20)
0.38 (0.006)

0.19 (0.17)
0.32 (0.02)
0.27 (0.06)
0.32 (0.02)

0.60 (0.0001)
0.44 (0.001)
0.47 (0.001)
0.39 (0.003)

0.29 (0.05)
0.21 (0.14)
0.31 (0.03)
0.36 (0.009)

Bolded values are statistically significant.

P.H. Lysaker et al. / Psychiatry Research 157 (2008) 3138

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

37

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. Additionally, metacognition was assessed using the same behavior sample
as that which generated the STAND scores. Accordingly, future longitudinal studies are planned with more
diverse groups of persons and which include longitudinal assessments of narrative and metacognition
derived from multiple sources.
References
Amador, X.F., Flaum, M., Andreasen, N.C., Strauss, D.H., Yale, S.A.,
Clark, S.C., Gorman, J.M., 1994. Awareness of illness in
schizophrenia and schizoaffective and mood disorders. Archives
of General Psychiatry 51, 826836.
Bebout, R.R., Harris, M., 1995. Personal myths about work and mental
illness: response to Lysaker and Bell. Psychiatry 58, 401404.

38

P.H. Lysaker et al. / Psychiatry Research 157 (2008) 3138

Bleuler, E., 1911/1950. Dementia Praecox or the Group of Schizophrenias Translated by J. Zinkin. International Universities Press,
New York.
Corrigan, P.W., 2003. Toward an integrated structural model of
psychiatric rehabilitation. Psychiatric Rehabilitation Journal 26,
346358.
Crowne, D.P., Marlowe, D., 1960. A new scale of social desirability
independent of psychopathology. Journal of Counseling Psychology 24, 349354.
Davidson, L., 2003. Living Outside Mental Illness: Qualitative Studies of
Recovery in Schizophrenia. New York University Press, New York.
Gallagher, S., 2000. Philosophical conceptions of the self: implications
for cognitive science. Trends in Cognitive Sciences 4, 1421.
Gallagher, S., 2003. Self narrative in schizophrenia. In: Kirshner, T.,
David, A. (Eds.), The Self in Neuroscience and Neuropsychiatry.
Cambridge University Press, Cambridge, UK, pp. 336353.
Harding, C.M., Zubin, J., Strauss, J., 1992. Chronicity in schizophrenia. British Journal of Psychiatry 161 (Suppl. 18), 2737.
Holma, J., Aaltonen, J., 1997. The sense of agency and the search for
narrative in acute psychosis. Contemporary Family Therapy 19,
463477.
Horowitz, R., 2006. Memory and meaning in the psychotherapy of the
long term mentally ill. Clinical Social Work Journal 34, 175185.
Jacobson, N., 2002. Experiencing recovery: a dimensional analysis
of recovery narratives. Psychiatric Rehabilitation Journal 24,
248254.
Koren, D., Sneidman, L.J., Goldsmith, M., Harvey, P.D., 2006. Real
world cognitive and metacognitive dysfunction in schizophrenia: a
new approach for measuring and remediating. Schizophrenia
Bulletin 32, 310326.
Lally, S.J., 1989. Does being in here mean there is something wrong
with me? Schizophrenia Bulletin 15, 253265.
Langdon, R., Coltheart, M., Ward, P.B., Catts, S.V., 2001. Mentalizing,
executive planning and disengagement in schizophrenia. Cognitive
Neuropsychiatry 6, 81108.
Lysaker, P.H., Lysaker, J.T., 2002. Narrative structure in psychosis:
schizophrenia and disruptions in the dialogical self. Theory and
Psychology 12, 207220.
Lysaker, P.H., Buck, K.D., 2006. Psychotherapeutic dialogue and
schizophrenia: movements towards recovery within client's
personal narratives. Journal of Psychosocial Nursing and Mental
Health Services 44, 2836.
Lysaker, P.H., Clements, C.A., Plascak-Hallberg, C.D., Knipscheer, S.
J., Wright, D.E., 2002. Insight and personal narratives of illness in
schizophrenia. Psychiatry 65, 197206.
Lysaker, P.H., Lancaster, R.S., Lysaker, J.T., 2003a. Narrative
transformation as an outcome in the psychotherapy of schizophrenia. Psychology and Psychotherapy 76, 285300.
Lysaker, P.H., Wickett, A.M., Campbell, K., Buck, K.D., 2003b.
Movement toward coherence in the psychotherapy of schizophrenia: a method for assessing narrative transformation. Journal
of Nervous and Mental Disease 191, 538541.
Lysaker, P.H., Wickett, A.M., Wilke, N., Lysaker, J.T., 2003c.
Narrative incoherence in schizophrenia: the absent agent-protagonist and the collapse of internal dialogue. American Journal of
Psychotherapy 57, 153166.
Lysaker, P.H., Carcione, A., Dimaggio, G., Johannesen, J.K., Nicol,
G., Procacci, M., Semerari, A., 2005a. Metacognition amidst
narratives of self and illness in schizophrenia: associations with
insight, neurocognition, symptom and function. Acta Psychiatrica
Scandinavica 112, 6471.
Lysaker, P.H., Davis, L.D., Eckert, G.J., Strasburger, A., Hunter, N.,

Buck, K.D., 2005b. Changes in narrative structure and content in


schizophrenia in long term individual psychotherapy: a single case
study. Clinical Psychology and Psychotherapy 12, 406416.
Lysaker, P.H., Wickett, A.M., Davis, L.W., 2005c. Narrative qualities
in schizophrenia: associations with impairments in neurocognition
and negative symptoms. Journal of Nervous and Mental Disease
193, 244249.
Lysaker, P.H., Buck, K.D., Hammoud, K., Taylor, A.C., Roe, D.,
2006a. Associations of symptom remission, psychosocial function
and hope with qualities of self-experience in schizophrenia:
comparisons of objective and subjective indicators of recovery.
Schizophrenia Research 82, 241249.
Lysaker, P.H., Taylor, A., Miller, A., Beattie, N., Strasburger, A.,
Davis, L.W., 2006b. The Scale to Assess Narrative Development:
associations with other measures of self and readiness for recovery
in schizophrenia spectrum disorders. Journal of Nervous and
Mental Disease 27, 233247.
Markowitz, F.E., 1998. The effects of stigma on the psychological
well-being and life satisfaction of persons with mental illness.
Journal of Health and Social Behavior 39, 335347.
Resnick, S.G., Rosenheck, R.A., Lehman, A.F., 2004. An exploratory
analysis of correlates of recovery. Psychiatric Services 55,
540547.
Ritsher, J.B., Phelan, J.C., 2004. Internalized stigma predicts erosion
of morale among psychiatric outpatients. Psychiatry Research 129,
257265.
Ritsher, J.B., Otilingam, P.G., Grajales, M., 2003. Internalized stigma
of mental illness: psychometric properties of a new measure.
Psychiatry Research 121, 3149.
Roe, D., 2001. Progressing from patienthood to personhood across
the multi-dimensional outcomes in schizophrenia and related
disorders. Journal of Nervous and Mental Disease 189, 691699.
Roe, D., Ben-Yishai, A., 1999. Exploring the relationship between the
person and the disorder among individuals hospitalized for
psychosis. Psychiatry 62, 370380.
Roe, D., Chopra, M., Rudnik, A., 2004. Coping with mental illness:
people as active agents interacting with the disorder. Journal of
Psychiatric Rehabilitation 28, 122128.
Semerari, A., Carcione, A., Dimaggio, G., Falcone, M., Nicolo, G.,
Procaci, M., Alleva, G., 2003. How to evaluate metacognitive
function in psychotherapy? The metacognition assessment scale: its
applications. Clinical Psychology and Psychotherapy 10, 238261.
Semerari, A., Carcione, A., Dimaggio, G., Nicolo, G., Pedone, R.,
Procacci, M., 2005. Metarepresentative functions in borderline
personality disorder. Journal of Personality Disorders.
Spaniol, L., Wewiorsky, N.J., Gagne, C., Anthony, W., 2002. The
process of recovery from schizophrenia. International Review of
Psychiatry 14, 327336.
Stenghellini, G., 2004. Disembodied Spirits and Deanimated Bodies:
The Psychopathology of Common Sense. Oxford University Press,
New York.
Wechsler, D., 1997. Wechsler Adult Intelligence Scale-III. Psychological Corporation, San Antonio, TX.
Whitehorn, D., Brown, J., Richard, J., Rui, Q., Kopla, L., 2002.
Multiple dimensions of recovery in early psychosis. International
Review of Psychiatry 14, 273293.
Wright, E.R., Gronfein, W.P., Owens, T.J., 2000. Deinstitutionalization, social rejection and the self esteem of former mental patients.
Journal of Health and Social Behavior 41, 6890.
Young, S.L., Ensign, D.S., 1999. Exploring recovery from the
perspective of persons with psychiatric disabilities. Psychiatric
Rehabilitation Journal 22, 219231.

You might also like