www.elsevier.com/locate/schres

Schizophrenia Research

Associations of symptoms, psychosocial function and hope

with qualities of self-experience in schizophrenia: Comparisons

of objective and subjective indicators of health

Paul H. Lysaker a,b,*, Kelly D. Buck a, Kristin Hammoud a,

Amanda C. Taylor c, David Roe d

a Roudebush VA Medical Center, Day Hospital 116H, 1481 West 10th St, Roudebush VA Medical Center, Indianapolis, IN 46202, USAb Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, United States

c Indiana University Purdue University at Indianapolis, Dept of Psychology, Indianapolis, IN, United Statesd Institute for Health, Health Care Policy, and Aging Research, Rutgers University, NJ, United States

Received 9 September 2005; received in revised form 28 November 2005; accepted 7 December 2005

Available online 25 January 2006

Abstract

While changes in self-experience have been suggested to be an important element of recovery from severe mental illness,

little is known about how qualities of self-experience are linked with other indicators of health including objective measures

such as symptoms profiles and subjective measures such as hope. To examine these issues the narratives of self and illness of 65

persons with schizophrenia spectrum disorder were obtained prior to entry into rehabilitation and rated using the Scale to Assess

Narrative Development (STAND). STAND scores were then compared with concurrent assessments of hope assessed with the

Beck Hopelessness Scale (BHS), psychosocial function using the Quality of Life Scale (QOLS) and symptom profile defined

categorically using the Positive and Negative Syndrome Scale (PANSS). Results suggest that higher ratings of the STAND were

associated with greater expectations of perseverance on the BHS and higher levels of psychosocial function on the QOL. Lower

symptom profiles were similarly linked with higher STAND scores. Results suggest qualities of self-experience expressed

within personal narratives are linked to symptom profiles and subjective assessments of health. Theoretical and clinical

implications are discussed.

D 2005 Published by Elsevier B.V.

Keywords: Schizophrenia; Recovery; Symptoms; Narrative; Remission

0920-9964/$ - see front matter D 2005 Published by Elsevier B.V.

doi:10.1016/j.schres.2005.12.844

* Corresponding author. Roudebush VA Medical Center, Day

Hospital 116H, 1481 West 10th St, Roudebush VA Medical Center,

Indianapolis, IN 46202, USA.

E-mail address: plysaker@iupui.edu (P.H. Lysaker).

Conceptualizations of treatment outcome in schizo-

phrenia spectrum disorder have changed significantly

over the last 30 years. Initially, with a view of

schizophrenia as a condition characterized by steady

decline or persistent dysfunction, the aim of many

82 (2006) 241–249

P.H. Lysaker et al. / Schizophrenia Research 82 (2006) 241–249242

interventions was stability, or the absence of events

that might suggest further deterioration such as

symptom exacerbation, hospitalization, incarceration

or homelessness. As accumulating evidence has

suggested that a declining course is an exception

rather than a rule in schizophrenia (e.g. Harding et al.,

1992; Hoffman and Kupper, 2002) treatments have

expanded their targeted outcomes to include the

achievement of personally defined goals (Gingerich

and Mueser, 2005). Accordingly, stability has been

replaced as an outcome with the achievement of

health across multiple domains of recovery (Anthony,

1993; Corrigan, 2003; Liberman et al., 2002; Spaniol

et al., 2002; Roe, 2001; Whitehorn et al., 2002). As

summarized by Resnick et al. (2004), these domains

of recovery can be grouped into two different se7ts of

phenomena. The first involves objective assessments

of the absence of features of illness (e.g. the absence

of significant symptoms and adequate social and

vocational functioning). The second category is more

subjective and involves attitudes and life orientation

(e.g. the absence of significant symptoms and

adequate social and vocational functioning) and the

second category being more subjective and involving

attitudes and life orientation (e.g. hopefulness for a

good life ahead). Resnick and colleagues present data

from a large study which supports this conceptuali-

zation and suggest that symptoms, life satisfaction and

recovery orientation are related.

In addition to changes in life attitudes and orienta-

tion, two elements of the subjective domain of recovery

noted by Resnick et al. (2004) recovery for some may

also include changes in the qualities of self-experience

(Davidson, 2003; Lysaker and Lysaker, 2002;Williams

and Collins, 1999). Schizophrenia has been widely

characterized as involving fundamental alterations in

sense of self (Bleuler, 1911/1950; Roe and Davidson,

2005; Searles 1965; Stenghellini, 2004). It has been

suggested, for instance, that persons with schizophre-

nia experience a diminished sense of their lives as a

series of comprehensible events (Gallagher, 2003;

Holma and Aaltonen, 1997; Lysaker and Lysaker,

2002; Young and Ensign, 1999) and that they may

cease evolving an understanding of themselves as

meaningfully connected to others (Lysaker et al., 2003;

Roe et al., 2004). They may have trouble seeing

themselves as beings more than the sum of their

disorder (Roe and Ben-Yishai, 1999).

Given such alterations in self-experience it seems

logical that the subjective domain of recovery

described by Resnick and colleagues could include

changes in the qualities of self-experience including

the rediscovery of a sense of self as meaningfully

participating in life (Davidson, 2003; Lysaker and

Lysaker, 2002; Roe, 2005; Williams and Collins,

1999). This would be consistent with observations

that changes in self-experience may result from

improved function (Bebout and Harris, 1995; Roe,

2003) and/or that changes in persons’ experience of

themselves may facilitate changes in other domains of

function (Davidson, 2003; Lysaker et al., 2003; Roe,

2001). It is also consistent with recent qualitative

research (Jacobson, 2002; Roe and Chopra, 2003),

clinical reports (Lysaker and Buck, in press) and first

person accounts (Ridgway, 2001) which indicate that

as some experience wellness, they begin to express a

sense of themselves as able to affect the world and as

possessing social value.

Yet little is known about whether qualities of self-

experience in schizophrenia are related to other

indicators of health. Are they related to phenomenon

such as symptom profile, psychosocial function and

hopefulness? To date, one barrier to examining how

self-experience relates to other aspects that are

indicators of health is that most of the research on

self-experience in schizophrenia has been qualitative

(Davidson and Strauss, 1992; Lally, 1989; Roe and

Ben-Yishai, 1999) and thus not easily used to confirm

or disconfirm relationships with objective measures.

To address this problem, we have used a narrative

theory of self which stresses that sense of self can vary

from more to less coherent according to how it is

constituted within the stories one tells oneself and

others (Gallagher, 2000) to develop a semi-structured

interview and a scale to rate self-experience as

revealed in that interview. The interview, the Indiana

Psychiatric Illness Interview (IPII; Lysaker et al.,

2002), differs from other interviews in that it does not

directly pose beliefs for the participant to endorse or

decline but rather offers a forum for participants to

give voice to their own stories of themselves and their

challenges. The Scale to Assessment Narrative De-

velopment (STAND; Lysaker et al., 2003), which can

be used to rate the quality of a self-experience as

articulated within a narrative, provides an overall

index score and four subscales which separately

P.H. Lysaker et al. / Schizophrenia Research 82 (2006) 241–249 243

assess coherent experiences of deficits/challenges,

closeness with others; social value and an experience

of self as an active agent in life.

In the current study, we have rated narrative

interviews of participants with schizophrenia spec-

trum disorders using the STAND and compared those

ratings with concurrent assessments of symptoms,

awareness of illness, psychosocial function and self-

reported expectations of self-persistence. We reasoned

that if self-experience is related to other indicators of

health, then STAND scores would be correlated with

greater psychosocial function, hope and awareness of

illness. We similarly reasoned that participants with-

out significant levels of positive, negative and

cognitive symptoms using recently developed remis-

sion criterion (Andreasen et al., 2005) would have

higher overall STAND scores. To rule out the

possibility that the STAND merely assesses verbal

ability, we included a measure of verbal intelligence.

Lastly, we planned to examine associations of the

individual STAND scales with each of these other

measures for exploratory purposes. Of note, the

sample studied here includes persons willing to

engage in vocational rehabilitation. While this sample

may not generalize to all persons with schizophrenia,

we believed that this was a reasonable group to begin

to study given that as a group of persons with

significant deficits seeking to move towards recovery,

they are likely to be representative of many seeking

rehabilitation. Further, as a group perhaps midway

along a continuum of health, this group might display

a wide range of scores for our key variables allowing

for associations between variables to be meaningfully

studied.

1. Method

1.1. Participants

Participants were 64 adult men and one woman

with DSM-IV diagnoses of schizophrenia (n =40) or

schizoaffective disorder (n =25). These 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 initially recruited from the outpatient

Psychiatry Service of a VA Medical 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 prior to entering the study.

Excluded from the study were participants with

mental retardation. Active substance use was also an

exclusion criterion as it was reasoned to affect

performance on all measures. The mean age and

education of the sample was 47.7 (sd=6.8) and 12.2

(sd=1.4) years respectively. Participants had, on

average, 9.9 lifetime psychiatric hospitalizations

(sd=7.0) with the first occurring on average at the

age of 24.2 (sd=6.1).

1.2. Instruments

Positive and Negative Syndrome Scale: (PANSS;

Kay et al., 1987) is a 30 item rating scale completed

by clinically trained research staff at the conclusion

of the chart review and semi-structured interview.

Individual items are rated on a b1Q to b7Q scale with

higher scores reflecting greater psychopathology.

Previous assessment of inter-rater reliability for this

study using the intraclass correlation found good to

excellent intraclass correlations on all scale scores

and most items (35). To determine the absence or

presence of significant levels of Positive, Negative

and Cognitive symptoms we used criteria recently

proposed by Andreasen et al. (2005), in collabora-

tion with other international groups, as a definition

of symptom remission or absence using the PANSS.

This scheme suggests scores of mild or less (b3Q) onthe Hallucinations, Delusions and Unusual Thoughts

items of the PANSS connote the absence of

significant positive symptoms, that scores of mild

or less on the Conceptual Disorganization and

Mannerisms items connote non-significant levels of

Cognitive symptoms and that scores of mild or less

on Social Withdrawal, Blunted Affect and Lack of

Spontaneity connote the absence of significant

negative symptoms. The absence of overall signif-

icant symptomatology is then defined as a state in

which all of these symptoms are present at a level

of mild or less. This scheme may be the most

parsimonious account to date because it contains the

smallest number of items, and items with the

smallest possible conceptual overlap. Items were

rated as they occurred over the 30 days prior to the

interview.

P.H. Lysaker et al. / Schizophrenia Research 82 (2006) 241–249244

Scale to Assess Unawareness of Illness (SUMD;

Amador et al., 1994) 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 medica-

tion. Each of these items is rated on a five point scale

which ranges from b1Q (complete awareness) to b5Q(severe unawareness). The total score can accordingly

range from 3 to 15. Assessment of inter-rater

reliability for raters in this study was in the good to

excellent range (intraclass r =.90).

The Vocabulary subtest (VS; Wechsler, 1997) 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 where the expected population

mean is a 10.

Beck Hopelessness Scale: (BHS, Beck et al., 1974)

is a questionnaire that asks participants to endorse

statements as true or false as applied to them.

Individual items are then summed. In this study we

used the scale score for motivational hope (MH), or

expectations of whether one will make an effort to

influence one’s life. Examples of items in the

motivational scale includes: bI might as well give up

because I can’t make things better for myself.Q Thisscale has been used successfully with a wide range of

psychiatric populations in the past and its validity and

reliability are reported elsewhere. In a previous

account we have reported that this scale of the BHS

may be uniquely linked with prospective performance

in rehabilitation (Davis et al., 2004). Scores on this

scale range from 0 to 8.

Quality of Life Scale (QOL; Heinrichs et al., 1984)

is a 21-item scale completed by clinically trained

research staff following a semi-structured interview

and chart review. For the purposes of this study, we

were interested in the sum of three of the four factor

scores of the QOL. The first, bInterpersonal relations,Qmeasures the frequency of recent social contacts and

includes separate assessments, for example, of fre-

quency of contacts with friends and acquaintances.

The second, bIntrapsychic foundations,Q measures

qualitative aspects of interpersonal relationships and

includes assessments, for example, of empathy for

others. The third, bCommon objects,Q reflects com-

munity participation and includes assessment of

participation in common community activities. Good

to excellent inter-rater reliability was found for the

QOL factor scores for this study, with intraclass

correlations ranging from .88 to .93. The fourth scale,

bInstrumental Function,Q assesses work function and

since all participants were entering vocational reha-

bilitation it was deemed irrelevant. Using these three

scales scores can range from 0 to 102.

Indiana Psychiatric Illness Interview (Lysaker et

al., 2002) is the semi-structured interview developed

to assess illness narratives. A research assistant

conducts the interview which typically lasts between

30 and 60 min. 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 up with a

question about what has and has not been affected

by their condition in terms of interpersonal and

psychological life. In the third section participants

are asked whether and, if so, how their condition

bcontrolsQ their life and how they bcontrolQ 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 content. If the participant does not mention

hallucinations, the IPII interviewer does not inquire

about hallucinations. The interviewer may ask for

clarification when confused and may query non-

directively. The tone of the interview is directed to be

conversational and questions are not posed for

participants to solve. The interviewer’s task is to

elicit enough information to understand the story a

participant is telling, not to confirm or refute. The IPII

thus results in a narrative of self and illness that can

be analyzed in terms of the gestalt or larger story

being told and not merely the presence or absence of

specific beliefs.

The Scale to Assess Narrative Development

(STAND; Lysaker et al., 2003) was designed to assess

P.H. Lysaker et al. / Schizophrenia Research 82 (2006) 241–249 245

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 5-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 and summing

all four subscale scores derives the STAND total

score. The anchors for each subscale have been

presented elsewhere (Lysaker et al., 2003) along with

evidence of an acceptable degree of internal consis-

tency (coefficient alpha= .86) and inter-rater reliabil-

ity for the total score (intraclass correlation= .87). A

later study with a different sample of participants

demonstrated 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). A third study with another

sample found evidence that greater STAND total

scores were linked to higher self-esteem and

readiness for change (Lysaker et al., in press). For

the current study, three raters achieved a significant

degree of inter-rater reliability (intraclass correla-

tion= .88) using 10 transcripts. Overall scores also

demonstrated a significant degree of internal consis-

tency (Cronbach’s alpha= .71) with no scale ob-

served to detract from the overall level of

consistency. With each scale ranging from 1 to 5,

the total score can range from 4 to 20.

Table 1

Spearman’s Rho correlations of STAND scores with insight, psychosocial

Illness awareness A

WAIS III vocabulary .22

SUMD total score � .50*** �Quality of life total scorea .31*

Beck hopelessness motivation scale .00

*p b .05; **p b .01; ***p b .001.a Total did not include the instrument function scale since all participan

1.3. Procedures

Following informed written consent, diagnoses

were determined using the Structured Clinical Inter-

view for the DSM IV (SCID; 42). The SCID was

conducted by a clinical psychologist. Next, partic-

ipants were given the PANSS, SUMD, VS, BHS,

QOL, and IPII as part of a baseline assessment for a

study of Cognitive Behavior Therapy and work

outcome. The IPII and PANSS 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 with raters blind to partici-

pant identity, test performance, and symptom ratings.

Raters were not present during the PANSS, 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 were

previously rated for levels of metacognition and

temporal connections within narratives using different

procedures and different raters and has been published

elsewhere (Lysaker et al., 2005a,b).

2. Results

Mean and standard deviations of PANSS scores for the

selected items were: Hallucinations 2.64 (1.55), Delusions

3.58 (1.36); Unusual Thoughts 2.62 (1.20); Conceptual

Disorganization 2.71 (1.31); Mannerisms 2.68 (.92); Social

Withdrawal 3.42 (1.12); Blunted Affect 3.35 (.89); and Lack

of Spontaneity 2.15 (1.23). Mean and Standard Deviations

of STAND scores were as follows: Illness awareness 3.67

(1.23); Alienation 2.80 (1.31); Agency 3.57 (1.39); Social

Worth 2.92 (1.14); Total 12.94 (3.75). Mean and standard

deviations for other outcome variables were: Vocabulary

9.61 (2.91), QOL total 47.87 (11.91), BHS Motivation scale

6.01 (2.47), and SUMD total 7.84 (2.50). STAND scores

function and expectations of persistence

lienation Agency Social worth Total

.15 .01 � .01 .10

.13 � .07 � .23 � .34**

.34** .40*** .20 .41***

.29* .36** .14 .28*

ts were unemployed and entering vocational rehabilitation.

P.H. Lysaker et al. / Schizophrenia Research 82 (2006) 241–249246

were not significantly correlated with age, education, or

lifetime number of hospitalizations. STAND scores did not

differ between participants with schizophrenia vs. schizo-

affective disorder. Intercorrelations among STAND sub-

scales ranged from .22 (Alienation and Social Worth) to .49

(Agency and Social Worth). Twenty three participants met

criteria for non-significant positive symptom profiles, 43 for

non-significant cognitive symptom profiles, 18 for non-

significant negative symptom profiles and 6 for non-

significant overall symptom profiles.

To compare associations of the STAND with the

Weschler Vocabulary subtest, SUMD total score, QOL total

score and BHS Motivation scale, Spearman Rho correlations

were calculated. This nonparametric correlation was chosen

because the BHS and QOL scores were not normally

distributed. As revealed in Table 1, the Weschler Vocabulary

subtest was unrelated to STAND scores while Higher QOL,

BHS Motivation and SUMD overall awareness of illness

were all associated with higher STAND total scores. Given

multiple significant univariate correlations, a stepwise

multiple regression was conducted in which the QOL,

SUMD and BHS scores were allowed to enter to predict the

STAND total score. This produced a significant predictor

equation ( f(2,61)=8.94, p b .001) with the QOL and SUMD

total making significant ( p b .05) unique contributions

respectively accounting for 17% and 6% of the variance

of the STAND total (total R2= .23).

To determine the relation of STAND scores to symptom

dimensions, ANOVA were performed comparing the

STAND scores among participants with significant vs non-

significant positive, negative, cognitive and overall symp-

tom profiles. As summarized in Table 2, significant differ-

ences were found on STAND scores for participants with

Table 2

ANOVA comparing STAND scores among participants with significant a

Illness awareness Alien

Positive symptom profiles

Non-significant (n =23) 4.13 (1.14) 3.04

Significant (n =42) 3.44 (1.24) 2.70

F 4.86* 1.01

Disorganized symptom profiles

Non-significant symptoms (n =43) 3.93 (1.21) 2.87

Significant symptoms (n =22) 3.20 (1.17) 2.70

F 5.30* .18

Overall symptoms

Non-significant symptoms (n =6) 4.33 (1.63) 4.12

Significant symptoms (n =59) 3.42 (1.12) 2.69

F 1.83 7.85*

*p b .05; **p b .01.

significant vs non-significant Positive, Cognitive and

Overall symptom profiles. No significant differences were

found on STAND scales for the significant vs. non-

significant Negative symptom profile group. Finally, a

discriminant function analysis was performed in which the

four individual STAND scale scores were allowed to enter

to predict membership in the significant vs non-significant

overall symptom profile groups. This produced a significant

overall correct classification rate of 74% (v2=9.62, p b .05)with 4 of the 6 (67%) participants without significant

symptoms correctly classified and 44 of 59 (75%) partic-

ipants with significant symptoms correctly classified.

3. Discussion

While the qualities of self-experience have been

hypothesized as an element of recovery, this is the first

study we are aware of to compare quantitative

assessments of self-experience with other clinical

and social indicators of wellness. Results suggest

there is significant overlap between more objective

outcomes and a quantitative assessment of self-

experience in schizophrenia. Persons rated as having

higher levels of psychosocial function tended to

construct narratives in which there was greater

articulation of personal difficulties coupled with a

greater experience of agency and intimate connection

with others. Persons who reported greater expect-

ations that they would persevere expressed in their

narratives more agency and connection to others. The

absence of significant positive symptoms was associ-

nd non-significant PANSS symptom profiles

ation Agency Social worth Total

(1.49) 4.13 (1.39) 3.09 (1.20) 14.39 (4.09)

(1.18) 3.27 (1.32) 2.85 (1.11) 12.23 (3.34)

6.00* .67 5.25*

(1.35) 3.89 (1.30) 3.17 (1.09) 13.73 (3.61)

(1.21) 3.14 (1.52) 2.45 (1.11) 11.56 (3.65)

3.41 6.26* 5.19*

(1.32) 4.83 (.40) 3.50 (.83) 16.83 (3.31)

(1.22) 3.49 (1.40) 2.87 (1.15) 12.61 (3.39)

* 5.70* 1.66 7.65**

P.H. Lysaker et al. / Schizophrenia Research 82 (2006) 241–249 247

ated with narratives in which persons better articulated

their difficulties and challenges and tended to expe-

rience themselves as able to affect the course of events

in their lives. The absence of significant cognitive

symptoms was also linked with more articulate

presentations of psychiatric difficulties and challenges

and the experience of a greater sense of worth within

one’s community. The absence of any significant

symptom was correlated with a greater experience of

agency and more intimate ties to others.

While the correlational nature of this study pre-

cludes the drawing of any causal connections, results

may suggest some hypotheses for future research.

Regarding subjective aspects of health and recovery, it

is possible that fuller self-experience is necessary for

the development of social relations or that one must

have hope and social connection for a fuller self-

experience. It is additionally possible that both exert a

mutual influence over one another (Roe, 2005).

Additionally, it may be that cognitive symptoms make

it especially difficult to see oneself valued in the eyes of

others. Certainly this is intuitively consistent with

observations that the ability to meaningfully link ideas

together could be essential for any complex self

narrative to be constructed in an ongoing manner

(Lysaker and Lysaker, 2002). Results could also be

interpreted as suggesting that the presence of a

significant positive symptom profile represents a

particular barrier to persons seeking to see themselves

as active agents in the world. Again it seems a matter of

intuition that intrusive hallucinations which occur

beyond one’s control as well as a sense of oneself as

perpetually in danger could interfere with the construc-

tion of a sense of self as able. It is also possible that with

greater decrements in self-experience, persons are also

more vulnerable to symptoms. Importantly, these

speculations await future longitudinal research, and

there aremany rival hypotheses that cannot be ruled out.

Indeed, consistent with models of how cognitive

therapy helps reduce positive symptoms (Haddock et

al., 1998), it is possible that as persons with schizo-

phrenia see themselves as more capable and able to

cope, it becomes easier to manage positive symptoms

and consequently the severity of those symptoms

decreases. It is also possible all relationships observed

with the STANDweremediated by factors not assessed.

While this was largely an exploratory study there

were some surprising findings. The STAND scores of

participants with significant vs. not significant nega-

tive symptom profiles did not differ significantly. This

may reflect, as noted by Andreasen and colleagues

(2005), that negative symptoms can result from many

different sources. For example, negative symptoms

may be linked to cognitive dysfunction (e.g. Bryson et

al., 1997), or, as suggested by Corin (1998), with-

drawal for some may be a means to establish a more

solid identity or help a person manage particularly

difficult periods (Strauss et al., 1989). Thus, perhaps

for some, negative symptoms may hamper narrative

development while for others it may be paradoxically

helpful, resulting in no single pattern of association

with narrative qualities. We were also surprised that

while illness awareness was linked to a traditional

measure of insight, no other STAND scale was linked

to this measure. This may suggest insight assessed

through direct interviews may tap related but different

phenomena than what is assessed when persons are

given a larger forum to articulate their views. This

finding is consistent with the conceptualization of

insight as including descriptive facts that could be

differentiated from narrative facts in terms of the kind

of information each intended to communicate. It has

been argued (Roe and Kravetz, 2003) that descriptive

facts may serve essentially to provide a reliable

account of states of affairs while narrative facts may

represent attempts to communicate the specific

emotional experiences associated with a series of

events and to gain control over these events by

transforming them into a story. Again as with all

unexpected findings these thoughts are preliminary

and await replication before they should be given any

weight.

There are also limitations to this study. Sample size

was modest in relation to the number of comparisons

made. Although we utilized more conservative two

tailed tests, and despite unidirectional hypotheses, risk

of spurious findings was increased. Generalization of

findings also is limited by sample composition.

Participants were mostly males in their forties willing

to enter rehabilitation. They were thus a group in

some sense healthier than some groups but perhaps

less healthy than others. They were willing to try

vocational rehabilitation and held success as a

possibility for themselves but, on the other hand, they

were not working and thus had much progress to

make in the vocational domain of recovery. It may

P.H. Lysaker et al. / Schizophrenia Research 82 (2006) 241–249248

well be that a different relationship exists between

symptom remission 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, symptoms were assessed

only over the course of one month while the

recommendation of Andreasen et al. (2005) is that

symptoms be assessed over six months. Finally, it is

unclear what symptom absence represents in this

sample. It could be that they may not have previously

had symptoms in that domain and thus we may be

more accurately assessing symptoms absence. Ac-

cordingly, future longitudinal studies of symptoms

and narrative constructs are planned with more diverse

groups of persons which address issues of recovery or

improvements from previously levels of function.

With replication, the STAND may come to have

clinical implications. STAND subscale scores may

serve to point to areas of need as persons move toward

wellness. For instance, the presence of lower illness

awareness scores may suggest a need for a treatment

which helps persons grasp the fuller meaning of their

deficits, while lower agency scores may suggest a

treatment which assists persons to focus on their

strengths and challenge beliefs regarding helplessness.

As illustrated in a recent case study (Lysaker and

Buck, in press) repeated assessments of counseling

transcripts using the STAND may also provide an

empirical assessment of progress and bring to

clinician’s attention areas that they might want to

inquire about further.

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