Coping with Illness Experiences in Patients with Schizophrenia: The Role of Peacefulness

Abstract

Background: The relationship between spirituality and schizophrenia is a largely unexplored, yet important area of research in psychiatry given its role in recovery from mental illness and in long-term care. Peacefulness, as one of the primary consequences of spirituality, was found to be most prominently associated with the emotional well-beings. This analysis aims to explore the concept of peacefulness among schizophrenic patients and its effect on their illness experiences.

Methods: Eighteen early-stage schizophrenic patients were recruited from the outpatient clinic of a hospital in Hong Kong for an in-depth individual interview. Data were analyzed with grounded theory techniques.

Results: Peacefulness has an emotional component and a cognitive component. The participants described peacefulness as a carefree state of mind that consisted of an inner sense of tranquility (the emotional component) and perceived freedom (the cognitive component). Their illness experiences were a vicious circle that was formed and maintained by distress (negative emotions) and preoccupation (distorted cognition). They believed that an inner sense of tranquility (the emotional component) facilitated the regulation of their distress, leaving them more cognitive resources to stabilize their chaotic minds, whereas perceived freedom (cognitive component) created an intra psychic moment and space with no stress to free the patients from their preoccupation.

Conclusion: Peacefulness is able to break the vicious circle of patient’s illness experiences by moderating distress and preoccupation. In addition, it may help promote patients’ personal resilience and self-efficacy, which are important for coping with residual symptoms, maintaining the patients’ mental health and preventing relapse.

Keywords: Schizophrenia; Peacefulness; Spirituality; Grounded theory; Coping; Chinese

Introduction

Since the late 19^th century, with the influence of the materialistic concept of medicine, individuals who bring intense spiritual experiences into their treatment have been viewed as mentally ill [1- 5]. The spiritual dimension of life and care has therefore tended to be avoided and ignored by mental health professionals [6]. In recent decades, spiritual factors have begun to draw a great deal of attention in the areas of mental health care and research [7], partly because a body of literature has documented a positive relationship between the practice of spirituality and health outcomes [8-10]. Spirituality is now considered to be a critical internal resource for people with chronic illnesses [11].

Although empirical evidence and even the definitions and concepts of spirituality have been incongruent among studies, the consequences of spirituality have tended to remain consistent [12]. The consequences of spirituality refer to the attributes and status after the occurrence of spiritual activities or a spirituality-related intervention [13]. In a report on concept analysis of spirituality with an evolutionary approach, Weathers and co-workers [14] identified several primary and secondary consequences of spirituality, including deep feelings such as a sense of inner peace, inner strength, and wellbeing as primary consequences and positive feelings such as hope, love, joy, and compassion as secondary consequences.

A sense of peace appears to be one of the most important primary consequences because it helps patients cope with different types of adversity, including mental illness [15,16]. In research conducted with the most used and validated instrument for assessing spiritual well-being (FACIT-Sp 12) [11-17], the factor of peacefulness was found to be most prominently associated with emotional wellbeing (positive relationship) and anxious preoccupations (negative relationship) [15]. A recently published analysis of the FACIT-Sp scale further confirmed these findings by revealing that the peace factor alone accounted for 35% of the variance in the emotional well-being domain and was related to most of the health outcomes [18]. Shah and coworkers [19] had similar findings in patients with schizophrenia using the WHO Quality of Life-Spirituality, Religiousness and Personal Beliefs (WHOQOL-SRPB) instrument. The inner peace domain of spirituality accounted for 21.6% to 37.6% of the variance of all quality-of-life domains [19]. From this evidence, the factor of peacefulness in spirituality appears to have potential benefit for people with mental illness because it helps to stabilize emotions and enables individuals to access their inner resources to cope with the illness [15]. Nevertheless, peacefulness has long been studied as a sub construct of spirituality without receiving full emphasis, and independent research on this factor is very limited [15], particularly in patients with chronic and severe mental illnesses such as schizophrenia. The importance of peacefulness in their recovery may be underestimated.

Given their particular mental state, individuals with schizophrenia may have concepts and interpretations of peacefulness that differ from those of people without mental illness. This possible distinction has received little or no attention or effort. Most of the existing measurement scales adopt a concept of peacefulness that has been constructed mostly by researchers. Therefore, to understand the role of peacefulness from the perspective of patients with schizophrenia, this study was initiated to explore the concept of peacefulness among these individuals and its effects on their illness experiences. These findings were generated as part of a larger qualitative study on the role of spirituality in the recovery process in patients with schizophrenia from the perspectives of patients, healthcare professionals, and family caregivers. A qualitative approach was used because the focus of the study was the individuals’ subjective human experiences [20]. An exploratory qualitative design with a grounded theory approach was used because it allows researchers to study with an open attitude the manner in which participants interpret their personal experiences in natural settings without any presumptions [21]. Several qualitative studies have demonstrated the feasibility of studying the personal views of patients with schizophrenia and the value of the results gained [22-24].

Methods

Participants

A purposive sample of participants with a clinical diagnosis of schizophrenia was recruited from the outpatient clinic of the Department of Psychiatry of Queen Mary Hospital in Hong Kong.

Individuals who were not inpatients or institutionalized, who were at a stable or early stage of illness without any neurological illnesses, cognitive impairments, other psychiatric disorders, or life-threatening medical illnesses that limited their life expectancy to 1 year were referred by their psychiatrist right after their regular medical follow-up appointment. Patients 18 years of age or older who consented to participate and were able to communicate in Chinese were included in the study. The recruitment of participants began in February 2012 and continued until July 2013, at which time data saturation was reached.

This study was approved by the Institutional Review Board (HKU/HA HKW) and the Research Ethics Committee (NTW) of the University of Hong Kong and the Hospital Authority. Written consent for participation was obtained from all participants before the interview commenced.

Data collection

After referral by a psychiatrist, the participants were immediately invited to an interview at the clinic or at the Centre on Behavioral Health at the University of Hong Kong, which is located in another building near the hospital. If time did not allow for an immediate interview, the participant was invited to schedule another time for the interview.

The interview guide was developed according to the existing literature on spirituality research. Special attention was paid to the appropriateness and sensitivity of cultural issues, particularly the use of language, during the interview. The interview guide included questions about the meaning and composition of spirituality, the patient’s illness experiences, and the relationship between spirituality and illness recovery. This analysis presents only the data related to the patients’ understanding of peacefulness and its relationship with their illness experiences. The interviews lasted about 60 to 90 minutes. All of the interviews were audio taped and transcribed. The participants’ demographic information (age, gender, education, living situation, and denominational affiliation) and the year of diagnosis were also collected before the interview.

Two research team members were involved in conducting the interviews to ensure their consistency. The interviewers carried out the first five interviews together and worked independently thereafter. Regular meetings were held among the research team members to discuss the research progress and to check for data saturation.

Data analysis

The recorded interviews were transcribed verbatim. Grounded theory techniques [25] and the qualitative analysis software ATLAS. ti was used for data analysis. To determine insights into the illness experience and the concept and influence of peacefulness, the transcripts were initially read word-by-word and line-by-line. In vivo codes [25] were used to label key information that corresponded to the components of peacefulness and factors regarding illness experience. Similar and repeated codes from different interviews were grouped into subcategories. The subcategories were then grouped into categories according to their distinct nature and characteristics. Regular meetings were held among the research team members to discuss and resolve discrepancies and disagreements in the assignment or grouping of codes and categories. A coding scheme was created to summarize all of the codes and categories and their relationships. To ensure trustworthiness, five interviews were randomly selected and coded by two independent coders. The interrater reliability was 85%, indicating a high degree of consistency between the coders.

Results

Participant characteristics

The sample included eight women (44.4%) and 10 men (55.6%) with an average age of 28.4 years. The majority (10 participants) had no religious beliefs. Five were Christian, two were Buddhist, and one claimed to practice a Chinese folk religion. The subjects had received a diagnosis of schizophrenia an average of 6.4 years earlier (SD, 2.8 years; range, 0.5 to 12.5 years).

Qualitative results

The concept of peacefulness: The participants described peacefulness as a carefree state of mind that consisted of an inner sense of tranquility and stability, as well as a perceived freedom from intangible constraints. These two components corresponded to emotional and cognitive axes, respectively. The patients described a sense of tranquility as a sense of not taking things more seriously than necessary. They described a no fluctuating, undisturbed emotional state that allows a person to behave or proceed in a calm and relaxed manner when encountering stress.

“Spirituality is a sense of peace… like those people who can stay calm when facing troubles… I have classmates who are always like this… no matter how urgent the homework is… (They would say) “I still haven’t done it, but no big deal.” (P001)

“(Spirituality) refers to as sense of peace, stability, and tranquility… a moment of staying calm… when you have this (calmness) … it’s like when you have to hand in an assignment, (you would feel) okay…take it easy… that is, you would feel that time is expanded.” (P024)

The patients described perceived freedom as an intra psychic moment and space with no stress. This freedom creates a perception of a lack of constraints and thus enables a person to behave freely and voluntarily, implying a sense of taking control over his or her life.

“Spirituality means having comfort in your heart, without much pressure… that is, nobody urges you… there is no need to wait for someone else… you are free (to do whatever you want)… it’s kind of ‘zero pressure’… it’s a time of being on your own… you can listen to music if you want, or you can work as a volunteer if you want… that is, you can use the time freely… I think having your own time is very important… no matter what you want to do, even you are just lying in bed, and it’s a kind of enjoyment.” (P023)

Illness experiences: The participants described their illness experiences in two distinct but interrelated categories: negative emotions and cognitions. They described a vicious circle that usually started with a triggering event. A great deal of intense negative and fluctuating feelings and moods such as anxiety, fearfulness, and sadness would be elicited, resulting in a prolonged emotional disturbance. Due to the highly aroused emotional state, the participants would become oversensitive to and overwhelmed by external stimuli (i.e., nearby events and/or things said or done by others).

“My colleagues and I were quite close originally. But suddenly, I felt weird as well… our manager was moved to another shop and did not come back… Then, they thought… the one who always took good care of me is not here now … they started to bully me. This made me very upset, and I cried all the time and became very scared when I saw them.”(P013)

“I had always sensed a disgusting smell when I was taking a bus. This kept pestering me… gradually… I started to feel that it emanated from me. This made me very unhappy… scared of taking the bus… I didn’t know how to get back home by bus… and I was so scared of being stared at by others on the bus, covering their noses… I would be upset too and didn’t know what to do… I would cry on the bus… making myself very sad and distressed.” (P014)

Excessive sensitivity to surroundings would bring the issue to a cognitive level by inducing a perception that some extraordinary connection must exist between the participants and these stimuli. Many nerve-racking ideas, such as the suspicion of having ones in dread or having one’s life threatened or monitored, then developed to explain the connections.

“That time, I kept having a sense that others knew what I was thinking about… unhappy feelings were also known by others, so there was no privacy at all… even when I walked on the street and saw people laughing, I felt that they were laughing at me, saying bad things about me… I felt like I was being monitored and followed… that is, no personal freedom at all. (It seemed that) everybody knew (everything about) me.”(P011)

“That time, I became suspicious… always felt that something was happening and that everything was related to me. That is, magnifying something that may be very small…” (P013)

These ideas would gradually dominate the participants’ minds and give rise to a sense of insecurity, a loss of control over themselves or even a feeling of being controlled. They finally led to the onset of illness, which could be out of the participants’ awareness. The occurrence of delusions and hallucinations then intensified the negative emotions and thus maintained the cycle.

“I didn’t know I was having some problems at the very beginning… It then became more and more severe… Finally, I couldn’t stand it anymore, so I told my family about my situation. My dad brought me to a psychiatrist… at that time, I differed from ordinary people very much… I was easily influenced by my surroundings… so that I was losing my own self. Once someone moved, I would then think he was judging me… it’s like being controlled… losing my own world, losing my… self-control… feeling insecure… and scared all the time because I felt like everybody was keeping an eye on me so that I couldn’t take care of so many people at one time. I was so powerless… and thus living in fear all the time.”(P011)

“I could come up with something negative very easily, being influenced by the environment completely… That is, I couldn’t dominate the situation… when you couldn’t take control and were passive for a long period of time, you became more and more introverted… it’s like a vortex… a vicious circle.”(P028)

Role of peacefulness in illness experiences: The participants described being under the influence of the illness as having a mind full of chaos (i.e., a fluctuating emotional and cognitive state), which made his or her life unpleasantly challenging. Most of the participants desired a sense of peace that was missing in their heart during the course of the illness.

“When I feel annoyed, I would definitely listen to music. Music is most essential to my life. I can lose everything but I can’t live without music… (When I am listening to music) I feel very peaceful… I think it’s most comfortable for me.” (P013)

“I would stand in front of the temple… to let myself calm down, to not be so nervous. I seldom talk to others because I am not in good condition and I don’t want to let others know about my illness. I don’t even want to share my worries with others because I don’t think they can help me… so staying calm on my own is the only thing I can do.” (P014)

During a psychotic episode, the participants experienced emotions that were so disturbed that they could no longer stay calm and clear-minded. Their judgment and capacity to handle difficulties were severely affected. However, the calm and relaxed manner that underlies peacefulness facilitated the regulation of their negative emotions, leaving more cognitive resources to stabilize their chaotic minds. As a result, they could remain tranquil in adverse situations and think properly.

“When I was having the psychotic outbreak, I cried the whole day… so I felt very down and frightened. I stayed nervous all the time… but now I can be at ease… because I feel peace.”(P017)

“My emotions… would affect what I do. If I have this kind of peacefulness, I can overcome difficulties and get rid of stress easily. But if I feel irritated, it will reduce my capability of encountering stress.”(P001)

Emotional and cognitive disturbances created a sense of living in chaos, which the participants described as “being hit by a hurricane.” They were involuntarily occupied by many distorted cognitions. A sense of being trapped was generated and resulted in the participants having a very limited capacity to exert control over surroundings or even over themselves. The perceived freedom associated with peacefulness created a perception of “standing in the eye of hurricane.” It provided the participants with an intra psychic moment of taking time out from the “control” of delusions and hallucinations despite the continued presence of these symptoms.

“This illness is like a tornado… it destroys all the things you have…I once attempted to jump from a building… but eventually I didn’t… It was very dangerous that time. I was standing on the balcony, holding the balustrade tightly… at that time my mental state was extremely chaotic… (It had gone) very crazy. At the very last minute, I thought of God… (My entire being) got settled down [calmed down]. All the chaos stopped, and then someone came and pulled me back into the house.”(P001)

Discussion

This study examined the concept of peacefulness among individuals with schizophrenia and its effects on their illness experiences. Peacefulness in patients with schizophrenia comprised both affective and cognitive components. It referred to a tranquil and stable emotional state and also represented the cognitive ability to perceive freedom under certain circumstances. These two components are particularly important to people with schizophrenia. This finding is different from those in the existing literature, in which peacefulness has usually been regarded as an affective dimension of religiosity or spirituality [26] due to prominent associations with the affective components [15,26]. Our qualitative findings reflect a comparable but more diverse perspective.

In line with the psychological processes described in the cognitive model of psychosis proposed by Garety and her colleagues [27], emotional and cognitive disturbances, at the individual level, played a central role in the formation and maintenance of the positive psychotic symptoms. When asked to recall their illness experiences, most of the participants emphasized the emotional changes induced by a triggering event. Such emotional changes biased their cognitive processes and decreased their flexibility. When the thoughts became more and more uncontrollable, a range of positive psychotic symptoms began to emerge that in turn worsened their emotional states and gave rise to a feeling of being caught in a vicious circle. The participant’s may not have noticed the precise onset of their illness and been eager to find out the causes, but most of them highlighted their need to seek peace.

It is well-documented that an extremely negative affect leads to problematic everyday functions, activities, and social interactions [28] because of the increased impairment of a range of executive functions [29-34]. The participants illustrated that peacefulness helped regulate their negative emotions by inducing a sense of tranquility and stability so that they were able to restore their cognitive capacity for daily functioning.

When one’s mind is preoccupied by destructive thoughts and emotions, cognitive functioning becomes less flexible for the exploration of alternative views, gaining perspective, and problem solving. A sense of losing control over one’s mind develops. As a result, the person becomes negativistic and hostile, and has difficulty perceiving happiness. In the words of the Roman Emperor, Marcus Aurelius, “If you are distressed by anything external, the pain is not due to the thing itself, but to your estimate of it; and this you have the power to revoke at any moment.” Although no empirical studies have investigated the underlying mechanism, the participants’ experiences suggested that peacefulness grants them power to be freed from the cognitive preoccupations and empowers them to shape their lives [35].

The implications of this study are twofold. First, peacefulness may be a non pharmacological means by which to break the vicious circle of positive psychotic symptoms through moderation of the emotional and cognitive disturbances. Since the rise of abnormal neurobiology, schizophrenia has widely been considered as a severe brain disorder [36-40]. Therefore, current rehabilitation services aim to break the vicious circle by eliminating psychotic symptoms, and neuroleptic agents are usually the first-line treatment for people with schizophrenia [41]. Our study not only calls for attention to the non physiological needs of this population, but also suggests another approach to destroy the circle cultivating a sense of peacefulness that may complement the effects of neuroleptic agents.

Second, the recovery from negative emotions and the sense of being freed from preoccupation with symptoms (the two components of peacefulness) may help to promote patients’ personal resilience and self-efficacy, respectively. Tugade and Fredrickson [42] suggested that the ability to regulate negative emotions contributes to personal resilience. In the long term, the positive emotions induced through regulation of emotions could potentially assist in building resilience and provide a buffer against adversity in life [42]. Perceived freedom fosters a greater sense of self-control of negative emotions, which thereby increases coping self-efficacy [43]. Recent studies have suggested that self-efficacy is a key component in the process of recovery from mental disorders [44] because it engages the person to be involved in self-help [45]. These are enduring personal resources that are important for coping with residual symptoms, maintaining mental health, and preventing relapse.

This study has several limitations. The sample was restricted to a group of Chinese young adult outpatients from one hospital, all of whom were at an early stage of illness. The results can only be generalized to individuals with the same characteristics as those in the study. Individuals who are hospitalized or institutionalized, who are from other cultures, who have other mental disorders or a co morbid diagnosis, or who grow up in uncommon environments may define spirituality differently. Individuals who refused to join or were incapable of joining the study may also have differed from those who participated.

This study is the first to explore the concept of peacefulness among individuals with schizophrenia and its effects on their illness experience. It provides insights for future research on developing measures of peacefulness and investigating its effects on recovery from schizophrenia as well as clinical practices that concern spiritual care as part of an integrated program.

Acknowledgment

This study was supported by the General Research fund of the Research Grants Council (GRF/HKU 745511H). We would like to thank all of the participants in this study and also the medical staff, Dr. Tam, Fiona Yee Ki and Dr. Lee, Edwin Ho Ming in the Department of Psychiatry, Queen Mary Hospital, University of Hong Kong, for their help in the patient recruitment in this study.

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