Chapter 14 - Understanding the Interplay between Narrative Identity and Mental Illness: A Framework

Summary

In Chapter 14, we propose a framework for understanding the interplay between narrative identity, mental illness, and personal recovery. First, narrative identity may constitute a vulnerability to mental illness. If individuals grow up in a narrative ecology characterized by silencing, hostile coauthors, and/or maladaptive vicarious stories, they may struggle to narrate negative events in ways that support a positive view of themselves and others. When encountering stressful events, such vulnerable narrative identities may trigger symptoms in some individuals. Second, narrative identity is affected by psychopathology. Mental illness may disrupt the ongoing life story and give birth to the ill self, the negative self, and the self as different. Simultaneously, individuals may feel that they have lost their previous selves and the projected future becomes uncertain and bleak. Certain healthcare practices and negative master narratives may magnify this toxic change in narrative identity. Third, individuals may work with narrative identity to recover from the damage done by mental illness and negative narrative ecologies. We suggest that such narrative repair addresses the narrative identity costs presented in our analyses (e.g., fear of the ill self and the negative self) and boosts narrative identity resources (e.g., the growing, agentic, and dreaming selves).

In this chapter, we view our findings from a broader perspective, integrating them with ideas reviewed in earlier chapters. The main purpose of the book so far has been to provide analyses illuminating the impact of psychiatric disorder and resources for well-being from a narrative identity perspective. In this chapter, we expand our focus to also address the question of how narrative identity may be a vulnerability to mental illness. This is the first part of the framework we present. While our life story interviews cannot speak directly to this issue, as vulnerability must be prospectively examined before the eruption of disorder, we draw on ideas from Chapters 5 and 6 to suggest potential pitfalls for narrative identity. In the second and third part of the framework, we draw more directly on the analyses from Chapters 8–12 to illuminate how narrative identity is affected by mental illness and crucial for personal recovery. The purpose of this chapter is to compose a fuller understanding of how narrative identity and mental illness interact. While empirical findings discussed in earlier chapters support parts of the framework, much of it is still speculative awaiting further research. Despite this limitation, we believe our framework will assist researchers, experts-by-experience, and healthcare professionals to appreciate the complex interplay between narrative identity and psychopathology while providing the foundation for working with narrative identity to aid personal recovery. In Chapter 15, we build on this framework to outline our guide for narrative repair.

The Interplay between Narrative Identity and Mental Illness

Our findings can be viewed through different lenses, casting light on the significance of relationships, education, vocation, leisure activities, and treatment from a first-person perspective. Given that our starting point is narrative identity, we expand on our findings from this perspective and present insights on how narrative identity and mental illness interact. While backgrounding the superordinate themes of relationships, functional level, and treatment, these are still a part of the framework. They constitute the contexts for stories of costs (e.g., individuals narrate themselves as failures when illness interrupts education) and well-being (individuals construct stories of the growing self as a part engaging with treatment).

We present our framework employing a transdiagnostic perspective. This is partly for pragmatic reasons since we analyzed the life stories from a transdiagnostic perspective and in general found few differences between groups. Past studies of narrative identity in psychopathology have shown similar patterns across different mental disorders (see Chapter 6).^{37, 141, 148} We further ground this decision in research demonstrating transdiagnostic processes involved in mental disorders (see Chapter 2).^{50, 53} Still, we acknowledge that our participants do not represent all psychiatric disorders and that our approach was not well suited to detect diagnostic differences. We recognize that diagnostic differences in the interplay between narrative identity and psychiatric disorder may be likely. While we do not elaborate, future studies will hopefully illuminate this issue.

Our framework outlines how narrative identity may be a vulnerability to psychopathology, be affected by mental illness, and be crucial for personal recovery, but we do not claim that narrative identity acts alone. Rather, narrative identity is one piece of the puzzle in comprehending mental illness from a psychological and medical standpoint. A host of other factors, including personality traits, emotion-regulation, attachment patterns, and biological processes, are involved in psychopathology.^{6, 64, 192–194} Narrative identity is nested in the complex human mind and as such in dynamic exchange with other processes. However, we argue that narrative identity may be particularly important from a first-person perspective of individuals coping with mental illness, because they live through multiple life transitions and massive transformations in their inner worlds. Recall the idea that narrative identity moves to the forefront during times of change.¹⁰⁶ To create personal continuity, purpose, and meaning when mental illness periodically disrupts daily life and its associated selves (self as student, self as parent), narratives are essential. Stories are needed to explain how individuals fell into mental illness, what their disorder did to them, how they coped and grew better, why they relapsed, and what was important for finding their way back to thriving again. At the same time, individuals with mental illness sometimes lack tools for composing their lived and told stories. We elaborate on this vulnerability below. Note that while we describe the framework in general terms and believe it will hold explanatory power for many individuals with mental illness, it will not apply equally well to all individuals. The fit will depend on the unique pattern of experiences and interpretations in the person’s narrative identity.

Narrative Identity as a Vulnerability to Mental Illness

The first part of our framework concerns narrative identity as a vulnerability to psychiatric disorder. This idea parallels diathesis-stress models.⁵⁸ As alluded to in Chapters 6 and 7, we and others have demonstrated that individuals with a range of mental illnesses struggle to story their lives in adaptive ways.^{38, 41, 141, 148} The problems may take a variety of forms and depend on diagnoses. When living with mental illness, individuals may tell stories that are less coherent, fail to tie together events organized in time, incorporate plausible explanations for life changes, and lack reflections on how key chapters impacted them. In addition, such life stories place little emphasis on positive meaning, including growth and learning, or may do so in ways poorly anchored in experience. Individuals with psychopathology bring memories and interpretations suffused with powerlessness and social discord to the center stage of their stories at the cost of other memories that would support more adaptive narrative identities. These aspects of narrative identity may constitute vulnerability to mental disorder because they are liabilities when individuals confront life stressors, such as starting education, moving to a new city, and romantic breakup. Equipped with narrative identities that provide little scaffolding for structuring narratives of negative events and with little opportunity for emerging as active protagonists and experiencing the support of others, individuals may more easily fall victim to intense stress. Such stress could trigger cascades of symptoms and functional impairment in biologically and psychologically predisposed individuals.

Vulnerable narrative identities grow out of a variety of past experiences. As reviewed in Chapter 5, close others coauthor narrative identity from childhood and onwards.^{118, 122} Extensive research documents that troubled early relationships constitute a vulnerability to mental illness.^{69, 195} One effect of such negative interpersonal experiences could be that it depletes narrative resources. Many of our participants’ life stories carried clear evidence of massive relationship issues in childhood and youth. We witnessed stories of parental neglect, silencing of abuse, and social exclusion in school. Due to lack of opportunities for sharing stories, such dearth of social connection could erode capacities for narrating experiences to make sense of them and understand their implications for identity. With depleted narrative resources, negative events may prove overwhelming and defeat order and comprehension, paving the way for chaos “narratives.”^{11, 121}

A second type of vulnerable narrative identity may surface when individuals fall victim to massive traumatic events. Recall our participant from Chapter 3 who protected her mother from being beaten by the alcohol-abusing father and who was placed in foster care. Events such as these are well-known risk factors for psychopathology and associated with a range of processes that can trigger mental illness.^{69, 196, 197} At the same time, traumatic events are raw material for building a negative narrative identity¹⁵⁶ and their harmful impact may double if individuals interact with hostile coauthors who insist on identity-defeating interpretations of blame and inadequacy.

Finally, the local narrative ecology may brim with toxic vicarious life stories,¹¹⁸ leaving individuals with few story models to assist them in narrating negative events with more adaptive meaning. From such negative narrative ecologies, narrative identity may unfold into versions casting individuals as passive victims, stunted in their growth, and others as unhelpful or even harmful.

We present narrative identity as a possible candidate for preexisting vulnerability that together with other risk factors may trigger mental illness in some individuals. It has been argued that some experience with storying difficult events is needed to craft a resilient narrative identity that can support adaptation in times of stress.¹¹⁸ We agree with this notion and emphasize that vulnerable narrative identities may emerge from erosion of narrative capacities stemming from neglect, exclusion, and silencing; from overwhelming traumatic events coupled with hostile coauthors and lack of adaptive story models. Such circumstances may lead to narrative identities with little potential for coherence, agency, communion, or positive meaning. Crucially, we do not understand vulnerable narrative identity as stable, it can wax and wane with shifting life events, changes in other aspects of personality, and evolving narrative ecologies. As we expand on in the next section, the eruption of psychopathology may push individuals to spotlight negative meanings of the past to make sense of their illness, shifting their narrative identity toward the ill self, the negative self, and their sources.

Psychiatric Disorder Affects Narrative Identity

The second part of our framework concerns how mental illness disrupts narrative identity and is grounded in the subthemes we discovered when analyzing negative consequences for narrative identity in Chapters 9–12, including the ill self, the negative self, the self as different, loss of previous self, and the bleak, uncertain future self. The disorder may sever the threads of individuals’ ongoing narratives, leaving them with little connection to their past story and a future that dissolves as the ill self takes over, teeming with chaos, division, and loss of control, throwing self-care to the wind. In acute crisis, the ill self dominates with lived turmoil, confusion, and splintering, defeating the organizing power of verbal storying.¹²¹ At other times, the ill self may share the scene with the negative self, featured in narrative identity conclusions of how weak, vulnerable, and fragile individuals feel as a result of their mental illness, submerged in self-criticism, self-blame, lack of trust in themselves, accompanied by shame and guilt. These negative identity conclusions may be reinforced when relationships are strained or lost. Individuals may silence the stories of their ill self and hide them from close others and themselves. They may struggle to accept the ill self into their life story and fear its full return in their future chapters. Illness and the costs that may flow from it (educational dropout, inability to work, and loss of independent living) push forward stories featuring the self as different and the negative self. When individuals reflect on how they miss one cultural milestone after another (as represented in the cultural life script, see Chapter 5),¹²⁸ they sense opportunities for a wished-for “normal” life escaping.

The previous selves from before mental illness seem lost, as the illness cuts through the fabric of these previous selves. When individuals drop out of education and vocation, suffer ruptured relationships, and struggle with independent living, they risk losing the associated valued, agentic, and growing selves, which may seem forever gone. Following Lars-Christer Hydén,¹³¹ we suggest that individuals may begin narrating their life from the vantage point of severe mental illness, so that the story starts to shift to provide explanations for how they became ill enough to attempt suicide or enter a psychiatric hospital or lose their ability to care for themselves. Healthcare praxis, such as collecting anamneses that emphasize illness-related events, may reinforce this story shift, by telling again and again when symptoms started to occur, identifying potential triggers, and generating reasons for worsening. While detailed information about the illness is essential in tailoring treatment to provide the best possible help, a single-sided zooming in on the illness story may foreground this story at the cost of others. As indicated in our analyses, adverse treatment experiences may foster the growth of negative identity conclusions. Furthermore, the attention of healthcare professionals and others who coauthor the narrative identities of individuals with mental illness, may be subtly guided by negative master narratives of mental illness. As the restitution master narrative may fit mental illness poorly,¹²¹ there is little help for structuring more adaptive illness narratives. Professionals may ask elaborate questions when narratives center on vulnerability, trauma, and deficit and overhear aspects testifying to strengths and resources. After all, they also need the story to make sense of why their patient is in so much pain and diathesis-stress models tell them to look for strain and liability. Such storying pushes the ill self, the negative self, and the self as different to the center of the stage, and fades out the agentic, valued, and growing selves, which are desperately needed for personal recovery. As this told story shapes the lived story, individuals’ actions begin to confirm the self-defeating story, feeding back into the told story. As a natural continuity, the bleak, uncertain future self overwhelms narrative identity, potentially leading individuals into a future darker than it needed to be. If individuals enter into mental illness carrying vulnerable narrative identities, the ill self and the negative self find fertile ground for rapid growth.

Some individuals may not experience clear moments of illness eruption. Rather, they narrate their problems as existing for as long as they can remember. Mental illness did not sever an ongoing narrative identity, it is a constant in their stories – a constant that may wax and wane, but with little sense of a self and a life before mental illness. While they may not story the consequences of their psychiatric disorder with loss of a previous self, their narratives could still feature the ill self, the negative self, the self as different, and the bleak, uncertain future self. Likely, their narrative identities would also shift gradually toward emphasizing these selves at the cost of the agentic, valued, accepting, and growing selves.

Narrative Identity as Contributing to Personal Recovery

The third part of our framework concerns how personal recovery can grow from narrative identity and we ground this part in our analyses of subthemes concerning sources of well-being in Chapters 9–12 (the valued, agentic, accepting, growing, and dreaming selves), while also borrowing from Paul Lysaker’s concept of narrative repair (see Chapter 6).¹³⁵ When the ill self dominates, lived chaos abounds and verbally narrating experiences is a challenge.¹²¹ Individuals may also shy away from stories even when the ill self subsides. Fear of its return and lack of acceptance can sabotage narrating how mental illness impeded life and robbed personal resources. Nevertheless, individuals need to story their mental illness to gain understanding and acceptance, and to repair the identity damage it did. Notably, this narrative differs in important ways from anamneses and other similar accounts elicited in traditional healthcare. It weights the subjective side of the story, the landscape of consciousness, to integrate it with the factual events, the landscape of action,⁹ typically emphasized in clinical interviews. This first step of narrative repair revolves around telling what caused the disorder, what it was like, what its course was, how they felt, and what it did to them and their lives: the costs to relationships, self, educational and vocational achievement, and basic daily and cognitive functioning with their accompanying toxic identity conclusions. The story may also incorporate grief for lost life and previous selves eaten up by the chaos of the ill self.⁶² Following Arthur Frank, the focal point in this first step is to narrate suffering.¹²¹ Ideally, this personal illness story provides framing for the pain, it structures the turmoil of guilt, shame, fear, grief, sadness, and anger to become understandable reactions to experiences, and it equips individuals with narrative tools to cope with both continued and remembered suffering in daily life.¹¹ Based on our analyses, we also suggest that individuals make room in their stories for potential positive impacts of mental illness on relationships and self, but resist the push of our culture to tell redemptive stories if this does not fit their experience.¹⁰⁹ The storying in this first step of narrative repair ignites insights into the narrative identity consequences of mental illness, which point toward the task ahead: searching for pathways to restore or discover a narrative identity which can guide individuals toward a life worth living. As evident in our analyses, storying treatment to foreground the agentic and growing selves that actively seek out help and collaborates with healthcare professionals to recover could be an essential thread in weaving personal illness stories directed at thriving.

The second step in narrative repair is to bring adaptive self-images and well-being experiences (back) into narrative identity. These include the valued self, the accepting self, the agentic self, the growing self, and the associated identity conclusions that surfaced from our analyses in Chapters 9–12. To scaffold this process, individuals can share past chapters and memories, reflecting on these positive selves as they are narrated in the contexts of relationships, education, leisure activities, vocation, and treatment (as evident in Chapters 9–12). These selves may be associated with goals, skills, values, interests, and roles that are either still evident in individuals’ daily lives or lie dormant waiting to be recovered. However, delving into the story of who one was before the eruption of mental illness can be a double-edged sword. The chapters may point to a cherished past perceived to be forever gone or it may point to a past that is an active resource today or at least partly possible to recover. Facilitating grieving for losses and at the same time vitalizing treasured aspects of the past,⁶² while also balancing these feelings and insights with present chapters, could be important to composing an enriching and sustainable narrative identity that can shape a good life.

The third step in narrative repair is projecting a desirable and realistic personal future flowing from the story work at the first and second step. It is a future that can inspire hope and ease present burdens, as captured by the dreaming self subtheme presented in Chapter 10. Individuals with mental illness may elaborate on this future and consider how they as protagonists in their own lives can bring the hoped-for future story into play through everyday actions with the help of close others and healthcare staff. To be adaptive, we suggest that such reflection needs be grounded in the present and the past rather than crafted as unanchored idealized images. Bring to mind our participant quoted in Chapter 10 who described future chapters of reconciling with her ex-boyfriend and studying medicine with few explanations of how she would bring this future to life. To be lived, the future story needs a beginning in concrete present circumstances and a protagonist ready to maneuver into place events that become stepping-stones toward desired future chapters. Recall also our participant quoted at the beginning of Chapter 5, who was in the process of completing her education, hoping to achieve an active work life. When she decided to get back on track, she knew she could not do it alone and started a study group at a day center. She was maneuvering an event into place that would become a bridge to her end goal of completing her degree.

Narrative repair requires supportive coauthors. Individuals must work continually to defy inaccurate stereotypes and negative master narratives (e.g., vulnerability and trauma leads to mental illness with repeated relapse and difficulties with social roles)²⁰ and they must resist falling back into the stories of the ill self and negative self they have habitually told and lived. Close others, healthcare professionals, and peers can hinder narrative repair if in conversation and action they feature the ill self and its dreaded fellows (the negative self, the self as different, and the bleak, uncertain future self).

Individuals need a warm narrative ecology for story repair. They require close others and healthcare professionals who through open questions, sensitive observations, and supportive actions emphasize the agentic, accepting, growing and valued selves; a social world that nurtures a recovering narrative identity and help settle the repaired story into place. They will benefit from peers who share their own stories of struggling with mental illness and working to recover; who offer vicarious stories that scaffold adaptive personal storying.¹⁸² In wider circles of the narrative ecology, individuals with psychopathology require master narratives of personal recovery depicting possibilities of living well with or after mental illness. Ideally, society would provide them with healthcare systems structured to facilitate citizen-led treatment and recovery support, with continuous personal and financial support during periods of illness debut, stability, relapse, and recovery; and with flexible opportunities for education and vocation besides the beaten track traveled by individuals who are lucky not to suffer from psychopathology. Such societal support would ease the path to crafting narrative identities that facilitate well-being.

Summary

• We outline an understanding of how narrative identity and mental illness interact.

• This framework comprises ideas about how narrative identity may be a potential vulnerability to psychopathology, how narrative identity is disrupted by mental illness, and how individuals can engage in narrative repair to foster thriving and personal recovery.

• Narrative identity as a preexisting vulnerability emerges from negative narrative ecologies including the absence of coauthors and hostile coauthors, which may erode individuals’ capacities for storying negative events in adaptive ways.

• Such vulnerable narrative identities can intensify stress in connection with life events and trigger mental illness in biologically and psychologically predisposed individuals.

• The emergence of psychopathology severs ongoing narrative identities, potentially sowing chaos and turmoil, dissolving the hoped-for future as identified in our subthemes of the ill self and the bleak, uncertain future self.

• The entrance of the ill self into narrative identity is accompanied by the negative self, the self as different, the bleak, uncertain future self as well as the loss of previous self, and narrative identity may begin to shift toward trauma, deficit, and vulnerability to make sense of mental illness.

• Existing healthcare practice, such as anamneses, stressful treatment experiences, negative master narratives as well as loss of relationships, education and vocation possibilities, can speed the growth of this toxic change and push the agentic, accepting, valued, growing, and dreaming selves identified in our analyses as needed for personal recovery, to the back of the story.

• To resist the ill self and its dreaded companions, individuals can engage in narrative repair, which includes working on a personal illness story that makes sense of and accepts the costs of mental illness while coping with fear of the ill self, loss of previous self, and the negative self.

• Narrative repair also involves constructing vitalizing stories that anchor valued, accepting, growing, and agentic aspects of the self and crafting hopeful, realistic future stories with stepping-stones toward projected, recovering selves (the dreaming self identified in our analyses).