Reconstructing a Sense of Self in Patients With

Chronic Mental Illness

Donna M. Czuchta, MSc(C),RN,and Barbara A. Johnson, MScN, RN

TOPIC. The loss and reconstruction of self in Donna M . Czuchta, MSc(C), RN, is a masters degree
candidate, University of Toronto, Toronto, Ontario, Canadn,
patients with a chronic mental illness. and a Clinical Psychintric Nurse, Mount Sinni Hospital,
Toronto. Barbara A. Iohnson, MScN, RN, is Associate
PURPOSE. To describe the loss of self and its Professor, Faculty of Nursing, University of Toronto.

reconstruction.
C h r o n i c mental illness has long been recognized as
SOURCES. The authors own clinical work and having an impact on an individuals sense of self
(Bleuler, 1950; Freud, 1958; Kraepelin, 1904; Sullivan,
review of the literature. 1940).Estroff (1981) writes that the chronicity of mental
illness involves more than just the persistent and recur-
CONCLUSIONS. Nurses can help patients who have rent nature of the illness; it also includes the relatively
permanent shifting of expectations and definitions of
undergone a loss of self to discover a more active self (p. 223). Estroff (1989) further describes schizophre-
nia as an I am illness-one that may overtake and rede-
sense of self, take stock of the self, put the self into fine the identity of the person. . . . Having schizophrenia
. . . results in a transformation of self as known inwardly,
action, and use the enhanced self as a refuge. This and of person or identity as known outwardly by oth-
ers (p. 189).Charmaz (1983) refers to the suffering of the
process involves the fostering of hope. chronically ill as a loss of self. A more optimistic view
allows that the self need not be permanently lost in
Key words: Chronic mental illness, hope, chronic illness,but can be recovered or reconstructed.

psychiatric n u rs ing,psychotherapy, Centrality of the Self

schizophrenia, self Fabrega (1989) writes that schizophrenia has the abil-
ity to alter and disturb an individuals customary sense
of self, sense of boundaries between self and others, and
the ability of the self to relate meaningfully to the cul-
tural world. Robinson (1974) defines the self as that part
of the human being that knows himself as I. It is the
thinking, knowing, feeling part of the human organism
which deals with the world (p. 19). Because it is pre-
cisely the thinking, knowing, and feeling parts of a per-
son that are so drastically affected by schizophrenia, this
condition has the power to transform ones sense of self.
Patients quoted in the literature express this notion
succinctly:

Like so many schizophrenic patients, I have my

own history of hospitalizations, medication trials,

Perspectives in Psychiatric Care Vol. 34, No. 3, July-September, 1998 31

Reconstructing a Sense of Self in Patients With Chronic Mental Illness
good and bad, setbacks, milestones, turns in the
road, light appearing and disappearing at the end of
the tunnel. I have seen lights in the sky, heard chc-
ruses of people inside me-taunting, tormenting
me, pinning me against the wall, driving me into
insanity. (A recovering patient, 1986)
Schizophrenia is a debilitating disease . . . it affects
your lifestyle, and your being able to take care of
your own, and your ability to deal with life situa-
tions. Youre not able as you once were, as I once
was. (Baker, 1996, p. 32)
There was something about me that people saw, but
I couldnt figure out what it was. . . . I imagned that
people thought I was dangerous because my actions
were so jerky. (Cunning & Dunne, 1989, p. 222)
The only way for nurse psychotherapists to come to
know how their patients sense of self has been affected
by their illness is to find out from them how they experi-
ence their world. First-person accounts have been recog-
nized widely as a rich source of information about
patients inner worlds (e.g., Hall, 1996; Hatfield, 1989;
Hatfield & Lefley, 1993; Strauss, 1994). As a patient
describes:
[Sluperficial support alone is not a substitute for
the feeling that one is understood by another
human being. (A recovering patient, 1986)
Recovery of the Self
Long-term follow-up studies of individuals with
severe mental illness indicate that optimistic outcomes
are possible (Brier, Schreiber, Dyer, & Pickar, 1991;
Carpenter & Strauss, 1991; Davidson & Strauss, 1995;
Harding, Brooks, Ashikaga, Strauss, & Brier, 1987).
Davidson and Strauss (1992) believe the development of
a functional self may be a unifying thread central to the
improvement demonstrated in these followup studies.
The reconstructed self allows individuals with a chronic
32
mental illness to maximize their ability to live, work, and
socialize in communities of their choice (Murphy, Gass-
Sternas, & Knight, 1995).
Deegan (1983, who is both a mental health consumer
and a mental health professional, draws a distinction
between rehabilitation and recovery when speaking
about those who are psychiatrically disabled. She writes
that these people are not passive recipients of rehabilita-
tion services. Rather, they experience themselves as
rmz~criizga new sense of self and of purpose within and
beyond the limits of the disability (p. 11). Deegans
notion of recovery is an optimistic one that affirms the
ability of individuals with psychiatric disabilities to
progress to a point of rediscovery of who they are and
what they can do.
A similar focus on the importance of the self in the
recovery process is evident in the work of Davidson and
Strauss (1993, who collected data from 66 people who
had been hospitalized for severe mental disorders. Semi-
structured interviews were conducted with each partici-
pant over a period of 2 to 3 years. The interviews
focused on the participants past and recent experiences
with respect to work and social relations, symptoms,
treatment, living situation, and coping efforts. The data
were examined to explore ways in which the sense of
self might have been a factor in improvement. The
researchers concluded that the recovery process indeed
involved the rediscovery, reconstruction, and use of a
more functional sense of self. They believed ths process
involved four basic aspects: (1 discovering the possibil-
ity of possessing a more active sense of self; (2) taking
stock of the strengths and weaknesses of this self and
assessing possibilities for change; (3) putting into action
some aspects of the self and integrating the results; and
(4) using the enhanced sense of self to provide some
degree of refuge from ones illness.
Clinical Illustration
In the following clinical example, the recovery process
is described according to the four aspects identified by
Davidson and Strauss (1992):
Perspectives in Psychiatric Care Vol. 34, No. 3, July-September, 1998
 Michael (not his real name) is a 33-year-old single
man with an 11-year history of schizophrenia. He has an
undergraduate degree in science and was doing gradu-
ate work when he experienced his first psychotic break
following his parents' separation. He has had several
hospital admissions during these 11 years. His latest fol-
lowed an acute exacerbation of auditory and command
hallucinations. Michael lives in a group home and works
when he is able as a part-time clerk in a religious book-
store.
Michael retains contact with his mother, who is s u p
portive, but has no close relations with his father, whom
Michael blames for the marriage breakup. He also has an
older sister who lives in another country but who keeps
in regular contact by telephone.
Michael is polite, articulate, intelligent, and has good
insight into his illness. Religion is an important part of
his life. When he is anxious, he hears the voices of Albert
Einstein and various musicians talking to him. He also
hears voices telling him to harm his mother.
Discovering a more active sense of self. Davidson
and Strauss (1992) describe this aspect of recovery as a
rediscovery of a part of one's self that has not been
affected by the illness and offers the possibility of an area
of competence. It is a re-awareness of a part of the self
that holds promise for a more active sense of self.
Michael "rediscovered" his sense of humor after a co-
patient commented on it. Michael perceived this as a
compliment and began to tell jokes during subsequent
ward meetings. Michael expressed what this meant to
him:
You know, ever since I can remember, people used
to comment on my sense of humor. It meant a lot
to me that my roommate commented on my ability
to make others laugh, even while we are all in hos-
pital. My sense of humor is something that I will
always have, no matter how sick I get.
Taking stock of the self. According to Davidson and
Strauss (1992), the second aspect of recovery involves the
person pausing to take stock of strengths and limitations
Perspectives in Psychiatric Care Vol. 34, No. 3, July-September, 1998
before taking on new tasks or returning to projects dis-
rupted by the illness. It is conducting a personal inven-
tory of one's capabilities before acting. Michael described
doing this as he contemplated his ability to leave the
security of the hospital:
I think I am ready for an increase in privileges
now. 1 know I still hear the voices, but 1 can control
them better now because of the guided imagery
exercises we worked on and the new medication I
am taking. Besides, if they get worse, I know to
return to the unit. I need to touch base with the
outside world again if I am ever going to return to
work at the bookstore. I miss it, you know. I miss
being outside with the trees and the sun and the
people around me.
Putting the self into action. Davidson and Strauss
(1992) described the third aspect of recovery as the indi-
vidual's putting into action this newly discovered and
newly inventoried self, and then incorporating the
results. As Mchael describes
Since getting a job at the bookstore, I always
wanted to start a small prayer group, in which we
could talk about different spiritual readings. What
really gave me the start in realizing I can do this
was ever since I had asked for the chaplain to
come and see me in the hospital. During one of
her visits, she let me borrow a book about prayer
and overcoming illness. What has been helpful in
reading this book is that I am slowly able to con-
centrate more, probably because of the new med
that I'm taking now. I have been reading this
book and sharing aspects of i t during the OT
[occupational therapy] social g r o u p on
Wednesdays. In fact, my roommate asked me
where I got the book, because it seemed pretty
interesting to him. . . . Actually doing this OT
social group feels like a dry run for me, for when I
want to run the prayer group at the bookstore,
once I am discharged.
33
Reconstructing a Sense of Self in Patients With Chronic Mental Illness
Using the enhanced self as refuge. In the final aspect
of the recovery process (Davidson & Strauss, 1992), the
self becomes an important tool in monitoring and man-
aging the illness. A sense of self, separate from one's ill-
ness, enables one to appeal to the self as something that
endures in the midst of symptoms. This strengthened
self allows the individual to be aware of potential
sources of distress and thereby develop and use coping
responses. Michael demonstrated this aspect of appeal-
ing to the self as he neared discharge and, in preparation
for that, was given permission to leave the unit unac-
companied. In a conversation with his primary nurse he
described attending a movie, something he had not done
for some time because his auditory hallucinations made
it hard for him to concentrate:
I was in the movie theater, waiting in line to get
some popcorn. It was really crowded around the
vending area. I started to feel really anxious and
kind of boxed in. I remembered what we talked
about to do when I felt this way. In fact, I remem-
bered all the positive feedback you gave me when
we role played this scenario during small group.
So what I decided was to go back to my seat, cool
down for a bit, and return to get my popcorn when
the line died down, and when I was feeling less
anxious. You know, it worked! I felt less anxious
and able to concentrate on the movie. I know your
belief in me made me realize that I can do this. I
was really proud of myself.
The Impact of Hope on Sense of Self
Davidson and Strauss (1992) write that interventions
to enhance a patient's sense of self should instill hope,
foster positive and yet realistic appraisals of self, and
encourage building on an individual's existing strengths.
Hicks (1989) believes that people with chronic mental ill-
ness must feel hopeful about their efforts to accept or
change the realities of their world. Miller's (1992) defini-
tion of hope captures the integral relationship between
hope and sense of self:
34
Hope is an anticipation of a future which is good
and is based upon: mutuality (relationships with
others), a sense of personal competence, coping
ability, psychological well-being, purpose and
meaning in life, as well as a sense of the "possible."
(p. 414)
Deegan (1988)also links hope to an active self in her
personal outlook
When one lives without hope (when one has given
up), the willingness to "do" is paralyzed as well . . .
But one day, something changed . . . A tiny, fragde
spark of hope appeared and promised that there
could be something more than all of this darkness.
(pp. 13-14)
Interventionsto Foster Hope
What can nurse psychotherapists do to help patients
feel hopeful about recovery? The fostering of hope to
facilitate the patient's recovery of self is closely and nega-
tively related to the concept of engulfment. According to
Lally (1989), engulfment "involves the person's self-con-
cept and behavior becoming increasingly organized
around the role of a psychiatric patient" (p. 255). It is
what Erikson (1957) describes as "the patient having to
seek definition as acutely sick and helpless in order to
achieve a measure of public validation for his illness . . .
submerging himself in the sick definition permanently"
(p. 271). Nurse psychotherapists help patients fight
against this engulfment when they foster in the patients
a sense of hope. Lally found that when patients viewed
themselves as competent, this self-view served as a
major factor in helping them cope with symptoms of
mental illness and hospitalization.
Landeen et al. (1996) interviewed 15 mental health
professionals representing a variety of disciplines about
ways they instilled hope in their patients. Responses
included believing in the patient; helping the patient
meet goals, in particular setting small achievable goals;
and persevering with the patient despite obstacles.
Perspectives in Psychiatric Care Vol. 34, No. 3, July-September,1998
 Michael recognized that his nurse psychotherapist's
interventions and belief in him resulted in his being com-
petent to handle the problems that arose when he
attended the movie. A patient quoted in the literature
also acknowledged the role played by the therapist in
helping that patient achieve what was important:
For me, the greatest gift came the day I realized
that my therapist really stood by me.. . and that he
would continue to stand by me and to help me
achieve what I wanted to achieve. (A recovering
patient, 1986)
Mental health professionals can help the patient
reconstruct the self by first getting to know that self.
Nursing, as a holistic discipline, is ideally suited to the
model of care that urges particular attention to the
patient's subjective experience. Hall (1996) writes that
nursing "as a relational field cannot set itself up as an
interpreter for anyone, including patient" (p. 26). By lis-
tening to our patients tell us their experiences and by
believing in them, we can work with them to build a
strong sense of self.
Peplau (1995)writes:
Nurses claim that advocacy for patients, and con-
sideration of their needs and interests as persons
having dignity and worth, are primary values
inherent in the design and execution of nursing
services. These values should be impliat in a nurs-
ing approach for the care of patients having a diag-
nosis of schizophrenia. In keeping with these
claims, it would behoove nurses to give up the
notion of a disease such as schizophrenia and to
think exclusively of patients as persons. (p. 2)
Deegan (1989) writes that "the most important voca-
tion for persons struggling with mental illness is the
work of becoming one's self in spite of one's illness" (p.
143). Nurse psychotherapists can work with patients in
ways that help them avoid the downward spiral of being
engulfed by their illness (McGorry, 1992) and help them
Perspectives in Psychiatric Care Vol. 34, No.3, July-September, 1998
recover their sense of self despite the challenges associ-
ated with having a chronic mental illness. With a posi-
tive sense of self, patients are empowered to meet these
challenges and emerge, as Michael did, triumphant and
proud.
Conclusions
Patients who have undergone a loss of self can be
helped by nurses to discover a more active sense of self,
take stock of the self, put the self into action, and use the
enhanced self as a refuge. This process involves the fos-
tering of hope.
References
A Recovering Patient. (1986). "Can we talk?" The schizophrenicpatient
in psychotherapy. Amerimn journal of Psychiatry, 143,68-70.
Baker, C. (1996). Subjechve experience of symptoms in schizophrenia.
Canadian ]ournu1 of Nursing Resaarch, 28(2),19-35.
Bleuler, E. (1950). Dementia praecox or the group of schizophrenias. New
York International UniversitiesPress.
Breir, A., schrriber, J.L.,Dyer,J., & Pickar, D. (1991). National Institute
of Mental Health longitudinal study of chronic schizophrenia.
Archives of General Psychiatry, 48,239-244.
Carpenter, W.T., & Strauss, J.S. (1991). The prediction of outcome in
schizophrenia IV:Eleven-year follow-up of the Washington IPSS
Cohort. ] o u ~ I of NOWUSand Mental Disease, 179,517-525.
Charmaz, K. (1983).Lossof self:A fundamental form of suffering in the
chronicallyill. Sociology of Health and Illness, 5,168-195.
Cunning. J., & Dunne, F. (1989).Subpchve experienceof schizophrenia.
Schizophrenia Bulletin, 15,217-231.
Davidson, L., & Strauss, J.S. (1992). Sense of self in recovery from
severe mental illness. British journal of Medical Psychology, 65,
131-145.
Davidson, L., & Strauss, J.S. (1995). Beyond the psychosocial model:
Integrating disorder, health and recovery. Psychiatry, 58,4445.
Deegan, P.E. (1988). Recovery: The lived experience of rehabilitation.
Psychosocial &habilitation journal, 11(4),11-19.
Deegan P. (1989).A letter to my friend uho is giving up. Paper presented
at the Connecticut Conference on Supported Employment,
Cromwell, (3.
Erikson, K.T.(1957). Patient role and social uncertainty: A dilemma of
the mentally ill. Psychintry, 30,2&274.
Estroff, S.E. (1981). Making it crazy. Berkeley, CA: University of
California Press.
35
Reconstructing a Sense of Self in Patients With Chronic Mental Illness

Estroff, S.E. (1989). Self,identity and subjechve experiences of x h i z ~ p h r e

nia: In stxch of the subject. Schizophrenia Btrllefin, 15,189-190.
Fabrega, H. (1989). The self and schuophrenia: A cultural perspechve.
Sclii~ophreniaBulletin, 15,277-290.
Freud, 5. (1958). Psychoanalytic notes on an autobiographical account
Visit PPC and
of a case of paranoia. In J. Strachey (Ed. and Trans.), The standard
edition of the cornplete psychological works of Sigmund Freud (Vol. 22,
pp. 3-82). London: Hogarth Press. (Originalwork published 1910). Nursecom online at
Hall, B.A. (1996).The psychiatricmodel: A critical analysis of its under-
mining effects on nursing in chronic mental illness. Advances in
Nursing Science, 18(3),16-26. www.nursecominc.com
Harding, C.M., Brooks, G.W., Ashikaga, T., Strauss, J.S.,& Breier, A.
(1987). The Vermont longitudinal study of persons with severe
mental illness 11: Long-term outcome of subjects who retrospec-
tively met DSM-111 criteria for schizophrenia. American journal of Download articles from the
Psychiatry, 144,n7-735.
Hatfield, A.B. (1989). Patients accounts of stress and coping in
schizophrenia.Hospital &Community Psychiatry, 40,1141-1145. journal, upcoming conferences,
Hatfield, A.B., & Lefley, H.P. (1993).Surviving mental illness: Stress, c o p
in8 and adaptation. New York Guilford Press. and services, or call us at
Hicks, M.B. (1989). A community sopurn from the perspechve of one
who relapsed. Issues in Mental Health Nursing, 10,137-147.
Kraepelin, E. (1904). Clinical psychiatry (6th ed.). (A.R. Deffendorf, 8001242-6757
Trans.) New York: Macmillan.
Lally, S.J. (1989). Does being in here mean there is something wrong
with me? Schizophrenia Bulletin, 15,253-265.
Landeen, J., Kirkpahick, H., Woodside, H., Byme, C., Bemardo, A., &
Pawlick, J. (1996).Factors influencing staff hopefulness in working
with people with schizophrenia. Issires in Mental Health Nursing, 17,
~~ ~

This puM8cation IS avatlable from UMI in one or more

45747. of the follwnng formats

McCony, P.D. (1992). The concept of recovery and secondary preven- * In Microforn--fromour collemon of m r 18,000
tion in psychotic disorders. Australian and New Zealand lournal of periodicals and 7.000 n-papers
Psychiatry, 26,3-17. * In Paper-by the arflcle or full lssues through UMI
Article Cleannghouse
Miller, J.F. (1992). Coping with chronic illness: Overcoming powerlessness
(2nd ed.).Philadelphia: Davis. * Elmmnially. on CD-ROM.online,and/or nugneric
ope--a broad range of ProQuest databases wadable.
Murphy, L.N., Gass-Sternas, K., & Knight, K. (1995). Health of the including abstract-and-index. ASCII full-tea. and
lnnovatie full-image format
chronically mentally ill who rejoin the community: A community
assessment.Issues in Mental Health Nursing, 16,239-256. call toll-free 8W-521-0600.ea 2888.
for more information.or (111 out the coupon below
Peplau, H.E. (1995). Another look at schizophrenia from a nursing
standpoint. In C.A. Anderson (Ed.), Psychiatric nursing 1974-1994: A
report on the state of the art (pp. 1-7). St. Louis: Mosby.
Robinson, L. (1974). Liaison nursing. Psycliological apprcucli to patient care.
Philadelphia:Davis.
Strauss, J.S. (1994).The person with schizophrenia as a person 11:
Approaches to the subjective and the complex. British journal of
Psychiatry, 164(Supp1.23),103-107.
Sullivan, H.S. (1940). Conceptions of modern psychiatry. New York:
Norton.

36 Perspectives in Psychiatric Care Vol. 34, No. 3, July-September,1998