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Psychosis
Psychological, Social and Integrative Approaches
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/rpsy20
A “blip in the road”: experiences of identity after a
first episode of psychosis
Phoebe Friesen, Jordan Goldstein & Lisa Dixon
To cite this article: Phoebe Friesen, Jordan Goldstein & Lisa Dixon (2021): A “blip in
the road”: experiences of identity after a first episode of psychosis, Psychosis, DOI:
10.1080/17522439.2021.1876159
To link to this article: https://doi.org/10.1080/17522439.2021.1876159
Published online: 05 Mar 2021.
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ARTICLE
A “blip in the road”: experiences of identity after a rst episode of
psychosis
Phoebe Friesen
a
, Jordan Goldstein
b
and Lisa Dixon
c
a
Division of Biomedical Ethics, Department of Social Studies of Medicine, McGill University, Quebec, Canada;
b
Independent Scholar;
c
Division of Behavioral Health Services and Policy Research, Department of Psychiatry,
Columbia University Medical Center, New York, NY, USA
ABSTRACT
Introduction: Psychosis can aect identity in fundamental ways.
Increasingly, those experiencing psychosis for the rst time are enrolled
in early intervention services. We sought to explore how individuals
enrolled in such services felt their identity was impacted by their experi-
ence of psychosis.
Methods: In-depth interviews exploring themes related to identity and
psychosis were conducted with 10 participants from two early interven-
tion services in New York City.
Findings: The experience of psychosis alienated many participants from
themselves, although participants diered in whether these experiences
were meaningful to their self-understanding. Participants also varied in
how they sought to explain their experiences of psychosis; some partici-
pants questioned their diagnoses and the explanations oered to them,
whereas others tried to negotiate between a clinical description of psy-
chosis and their own understanding of their experiences. Many partici-
pants also experienced positive changes following their experience of
psychosis, including greater maturity, empathy, and compassion.
Discussion: Some participants appeared to take on recovery styles of
both integrating and sealing-over in response to their experience of
psychosis, while most participants’ reports were suggestive of post-
traumatic growth. Several struggled to make sense of the explanatory
frameworks oered to them, drawing from various explanatory frame-
works in a form of bricolage.
ARTICLE HISTORY
Received 10 August 2020
Accepted 11 January 2021
KEYWORDS
Psychosis; identity; early
intervention services;
recovery styles; first episode
psychosis; post-traumatic
growth
Introduction
The centrality of identity within experiences of psychosis has long been acknowledged (Davidson,
2003). Schizophrenia, a diagnosis primarily characterized by psychosis, has been described as
a condition that “may overtake and redene the identity of the person” (Estro, 1989) while others
have suggested that “to experience psychosis [. . .] is to experience a radically changed self” (Jones &
Shattell, 2016). Recovering from psychosis has been described as a process of developing a new
identity (Larsen, 2004), which can include greater self-awareness (Jordan et al., 2019).
The link between identity and psychosis may be particularly pronounced during experiences of
First-Episode of Psychosis (FEP) (Ben-David & Kealy, 2020). Such experiences often occur during the
late teens or early twenties, a critical stage of development characterized by an increase in respon-
sibilities, the establishment of meaningful relationships, and the development of one’s identity
CONTACT Phoebe Friesen phoebe.friesen@mcgill.ca Division of Biomedical Ethics, Department of Social Studies of
Medicine, McGill University, Quebec, Canada
PSYCHOSIS
https://doi.org/10.1080/17522439.2021.1876159
© 2021 Informa UK Limited, trading as Taylor & Francis Group
(McGrath et al., 2016). Psychosis can take on a variety of emotional tones, from uplifting to terrifying,
which can magnify the emotional challenges of this stage of life (Hirschfeld et al., 2005).
Early intervention services (EIS), sometimes called coordinated speciality care programs in the
United States, are now widely considered the most eective form of care for individuals experiencing
FEP (Nolin et al., 2016). The EIS treatment model emphasizes the personal meaning of recovery, the
development of life goals, and achievement of those goals through one’s own means (Iyer et al.,
2015). In line with this, EIS emphasizes the importance of joint-decision making and engaging young
people in their own recovery, sometimes by encouraging those enrolled to re-assume the social roles
they previously held (e.g., in work or school) (Gergel & Iacoponi, 2017). EIS supports these goals by
providing a variety of psychosocial interventions, including, but not limited to, educational and
employment support, family therapy, peer support, psychotherapy, as well as medication manage-
ment with the support of a psychiatrist.
The development and growth of EIS in the treatment of psychosis suggests that how individuals
with FEP understand and experience identity in relation to psychosis may also be changing. The
importance placed by EIS on personal goals and recovery, as well as the roles that individuals play in
their families and at school or work, may impact how those enrolled in these services understand
their diagnoses, their prospects for recovery, and explanations for psychosis, all of which are
intimately linked to identity. As we shift away from a system of care in which diagnosis of schizo-
phrenia is received as “a prognosis of doom” and towards one in which those who have experienced
psychosis are encouraged to continue setting goals and engaging in personally meaning activities,
the identities of those enrolled in EIS are likely to be signicantly impacted (Deegan, 1997, p. 16).
While most research examining the link between psychosis and identity has focused on indivi-
duals with a long-term diagnosis of schizophrenia, a few studies have investigated the experiences of
those enrolled in an EIS. This small body of research indicates that individuals often report losing
their sense of self while experiencing psychosis, and that recovery can involve re-storing one’s
identity (Attard et al., 2017; Connell et al., 2015). Berkhout et al. (2019) report similar data, but
question whether self-fragmentation in psychosis should be understood as pathological, pointing
towards ways in which one’s identity is embedded within, and constituted by, relations of power.
Changes in identity following FEP have also been identied as an element of post-traumatic
growth (PTG) (Jordan et al., 2018, 2019). PTG is characterized by persons making stable positive
changes following an experience of trauma, tragedy, or illness (Jordan et al., 2019; Tedeschi &
Calhoun, 2004). Changes made through PTG can include reappraising one’s life and personal
priorities, developing new values and appreciation for life, increaing one’s empathy for self and
others, strengthening personal character or self-understanding, engaging in existential re-evaluation
, and developing new coping strategies (Noiseux & Ricard, 2008; Tedeschi & Calhoun, 2004).
According to McGlashan and colleagues, there is a spectrum of recovery styles between either
“integrating” or “sealing-over” the experience of psychosis (Levy et al., 1975; McGlashan et al.,
1976). Those who “integrate” believe their psychotic experiences are meaningful to their self-
understanding and try to understand how they t into their life experiences. This self-examination
can lead them to make substantive changes to their lives. Conversely, those who “seal-over” try to
put their psychotic experiences behind them without much examination and return to their
previous life. While McGlashan and colleagues acknowledged that there is a wide spectrum of
recovery styles between these extremes, they also found that the distinction was clinically relevant,
and that integration tends to be associated with recovery (McGlashan, 1987; McGlashan et al.,
1976).
More recently, this distinction has been explored in the context of EIS, where recovery style has
been associated with a number of outcome measures. Research indicates that integration is asso-
ciated with fewer symptoms (Staring et al., 2011; Thompson et al., 2003), higher quality of life
(Thompson et al., 2003), greater insight and more service engagement (Tait et al., 2004).
Conversely, a tendency towards a sealing-over recovery style has been found to be associated
with a more negative self-image and worse perceived quality of relationships with parents than
2P. FRIESEN ET AL.
integration (Thompson et al., 2003). Some qualitative literature also suggests that those who
integrate do better than those who seal-over in both the short- and long-term (De Jager et al.,
2016; Mapplebeck et al., 2015). As Gergel and Iacoponi (2017) have pointed out, however, this
remains an understudied area of recovery and causal relationships between these associations are
not well understood.
In this study, we sought to contribute to this growing body of literature through speaking to
several individuals enrolled at an EIS in New York City, in order to better understand how their
identities were aected by their experiences of psychosis.
Methodology
Recruitment
The project was approved by the Institutional Review Board of the New York State Psychiatric
Institute (#7314). Participants were recruited using yers posted in two EIS in New York City (NYC).
Those who expressed interest by phone or email (17 total) were screened to ensure they met the
eligibility criteria, which included being: 1) enrolled in the EIS for a minimum of 6 months, 2) between
the ages of 18– 30, 3) English-speaking. A 50 USD honorarium was given to each participant.
Interviews
Interviews took place in the same building as the EIS. Before the interviews began, a capacity
assessment was conducted by a psychiatrist familiar with the participant and oral and written
consent was given. Interviews were conducted by __; they lasted between 20 minutes and
an hour and were audio recorded. A semi-structured interview guide was covered several broad
topics (psychosis, identity, wellbeing). The interview guide included questions such as “Did these
experiences have an impact on your identity?” and “Would you describe yourself dierently before
and after these experiences?”. The term psychosis was not used within the interviews, unless
respondents introduced it themselves. The guide was developed by the research team, which
includes both a service user with lived experience of psychosis and a practitioner; feedback was
also sought from researchers who were conducting research in the same setting with the same
population. Short interview summaries were written up by PF after each interview, which were later
used to guide analysis.
Analysis
Thematic analysis of the transcripts was conducted by PF and JG using NVivo. After becoming
familiar with the transcripts, an initial coding frame was developed. This was revised multiple times
while several interviews were coded, until a nal version was decided upon, and the coding was
completed. The coding frames were made up of several themes, identied through patterns that
appeared across interviews, with a focus on how identity was experienced, understood, and
described by the participants. The analysis did not commit to an essentialist or constructionist
worldview, but understood the meanings and experiences reported by participants as both real
and structured by the sociocultural contexts they are embedded in (Braun & Clarke, 2006). A lived
experience researcher who joined the project later on (and chose not to be included as an author)
reviewed the raw data and developed a second coding frame independently, which overlapped
considerably with the original frame. The researcher and PF discussed dierences between the
frames and agreed upon the categories presented here.
PSYCHOSIS 3
Note on reexivity
PF is a philosopher, bioethicist, and advocate for change in mental health research, care and policy.
At times, she has played various roles in mental health services, including as a patient, volunteer, and
researcher. JG has lived experience of psychosis, a Master’s degree in Medical Anthropology, and has
worked as a peer specialist and in peer-run initiatives for several years. LD is a psychiatrist, researcher
and sister of a man with lived experience of psychosis; she has played various roles in mental health
services, including as a researcher, advocate, and patient.
Findings
Ten participants took part in interviews. Ages ranged from 19 to 27 with a mean age of 22. Seven
participants identied as male and three as female. Representing the diversity in the boroughs of
NYC where the programs were oered, the participants represented a variety of racial and ethnic
backgrounds; 4 identied as Hispanic/Latinx, 4 as Asian, 4 as Black, 1 as white (3 as mixed race).
Four inter-related themes regarding identity and psychosis were identied: 1) identity during and
after psychosis, 2) psychosis and meaning, 3) reconciling experiences with explanations, and 4)
positive changes to identity following psychosis. See Table 1 for more detail on the themes and
subthemes that were identied during coding.
Identity during psychosis and after psychosis
Six of 10 participants described having a dierent identity during psychosis:
P7: I think during the illness it was . . . I was a dierent person.
P5: I feel separate from that experience.
P12: While I was experiencing psychosis, I felt like everyone just took my personality and just threw it away and
I couldn’t nd it.
P15: I became like a whole new person, I did not care about, you know, like, I didn’t care about consequences or . . .
the the . . . way you know things could have turned out for me, by the way I was acting, um . . . I developed a whole
new mindset and demeanor that was like . . . almost outstanding in a sense, and it was like I was living in a fantasy.
Some also spoke of returning to themselves after psychosis:
Table 1. Themes and sub-themes.
Theme Codes
Identity During and After Psychosis Different identity during psychosis
Continuity of identity during Psychosis
Hiding a part of themselves
Parts of identity missing following Psychosis
Psychosis and Meaning Psychosis as meaningful
Psychosis as meaningless
Gaining self-understanding
Struggling to understand experiences of psychosis
Reconciling Experiences with Explanation Questioning psychosis as an explanation
Appreciating medical explanation of psychosis
Not being defined by diagnosis
Negotiating between explanations offered and their own
Positive Changes to Identity following Psychosis Greater maturity
More empathy and compassion
Greater sense of appreciation
New goals and priorities
4P. FRIESEN ET AL.
P7: Now that I’m back to normal I . . . it . . . um . . . I’m the same person as before the illness.
P16: Well . . . it feels sort of like I left myself and then I came back [. . .] I left my um . . . my . . . perception of reality
and . . . for a while I really wasn’t myself
P1: I felt like throughout the time and my recovery it just postponed my identity
Although the relationship between the two identities was also maintained for some:
P16: I guess I’m still, there’s some continuity here, it’s like a little blip in the road.
One participant felt that they had to hide who they were while experiencing psychosis:
P3: I felt like I was wearing a mask most of the time, like I couldn’t show people who I really was, cause I felt like
everyone could see through me, like I had a mental disease [. . .] It made me afraid to talk to people.
Others mentioned that part of themselves was missing afterwards:
P9: I look at my past, look at things, what I was doing, sometimes I be like . . . like I can’t do it no more, like
before . . . Like I used to hang out on the corner, like I don’t feel like . . . I don’t feel the same way sitting outside on
the corner no more . . . its like nothing don’t feel the same, nothing. Everything changed.
P12: I feel more like myself. Maybe there’s some things that’s still missing, but I feel condent and I feel good
with who I am right now.
Psychosis and meaning
Participants diered with regards to whether they saw their experience of psychosis as meaningful or
meaningless:
P7: I think it was more a meaningless expression of an illness
P16: The bullying happened in school, and it’s sort of like your own mind creates it, so I do believe it has meaning
[. . .] in my psychotic episode I had many delusions about being bullied [. . .] it showed me, even though the
bullying stopped at such, at such a young age, it showed that I carried it with me for so long.
One participant struggled to reconcile these possibilities:
P5: I don’t think it means anything. I think it just . . . it’s a chemical reaction in my brain.
P5: Therapy denitely helped with my . . . with my . . . getting to know myself and stu . . . but I think what’s more
crucial is the experience I had.
Relatedly, six participants (P4, 7, 12, 16) spoke of gaining further self-understanding through their
experiences:
P5: Didn’t know much about myself, denitely, and had low self-esteem, but didn’t realize what the problems are
and what the problems are, [. . .] but now I feel I know myself better
P3: I can tell people what I want better now
While two felt that they were still struggling to make sense of what happened to them:
P13: It just seems like maybe no one has like the answer that I’m looking for
P9: I feel like I don’t really understand myself at all . . . like what is going on . . . I feel like I’m clueless.
Reconciling experiences with explanations
Participants had a variety of responses to the way their experiences of “psychosis” were explained to
them. Some questioned whether they had actually had these experiences:
PSYCHOSIS 5
P13: This is the, you know, this is the psychosis clinic, and yeah. But then sometimes I think, like, oh you know,
sometimes Ithink wait a second, did I really have this in the rst place? What am I doing here?
P5: I never believed myself to have some kind of mental problem, except depression and anxiety, so these are
the problems but not, not, not more serious mental illness.
One participant found comfort in the distance between self and experience that can be created by
the term psychosis:
P16: Psychosis is a good word because it makes it sort of third entity - this thing is not you.
P16: I like to say rst break psychosis because it takes delusions, which was my primary symptom [. . .] and it
makes me say this was a time in my life that was the psychosis. I’m still scared a little bit, but its part of this other
umbrella of things that I don’t have to make part of my current reality.
Some participants emphasized that they were not dened by their diagnosis or that it was just
temporary:
P3: I feel like I don’t let my diagnosis, like, aect me. I don’t let it control my life.
P15: It’s only sprung up in the past three years, so I feel like this will be a temporary part of my life.
Others tried to negotiate between their own understanding of their experiences and the dierent
medical explanations being oered to them:
P15: If I could call it spiritual possession I would, but the scientic term is psychosis, so I’m going by the scientic
term.
P13: I guess when I’m talking to the psychiatrist, its always like, you know, there’s like a thing inside your brain,
you take the medication you’ll get rid of it. And then I’m like wait a second, [. . .] the thing inside my brain is me.
And I guess with [. . .] the multiple therapists I’ve talked to, it always, like, tends to like center around like my dad
[laughs] . . . so I guess that’s the identity that they give me. Its like you’re the son of this person that has created
you . . . but then I’m like wait a second, that’s only like a really like part
Positive changes to identity after psychosis
Six of 10 participants described positive changes to their identities after the experience of psychosis.
Three spoke of a greater maturity:
P12: I do think I changed a lot. Like maybe . . . a little more mature and serious.
P7: I mean like somethings, I think I take, I handle more maturely now . . . so I have like a bit more understanding
of certain issues.
P13: I feel like I’ve learned some things and could handle things better.
Two felt they developed more empathy and compassion for others:
P7: I did retain, or obtain more empathy towards people who have related illness.
P16: It’s sort of given me a lot of compassion for people with mental illness [. . .] And it makes me feel a lot of
compassion and a lot of understanding that in society we have to help one another [. . .] so it denitely aected
my identity, in terms of the way that I see the world now
Two described a greater sense of appreciation:
P12: I do think this changed me to become a better and appreciative person.
P7: . . . more appreciation of being, like, healthy
6P. FRIESEN ET AL.
One participant also spoke of being “more positive”, “more open”, and “careful” (P12) while
another said that they “pay attention to things more” (P9). Others spoke of being less critical of
themselves, and developing new priorities and values:
P16: I’ve denitely lost that . . . that voice of judge in my head, like that feeling of like I’m doing this wrong
P2: Before like I didn’t really have any goals, it was just kind of like get out of high school [. . .] I have a set of goals,
things I want to get accomplished
Another participant said they would describe themself dierently before and after the experience:
P5: So before I would use words like university student, like I had a job in nance, something about status, to
dene myself. But now I would use some characteristics, quality of myself, virtues, like what are my virtues, to
dene myself.
Discussion
As in previous research, these interviews with individuals enrolled at an EIS revealed a wide variety of ways
individuals came to understand their identities in relation to their experiences of psychosis. In these
interviews, several participants felt they were a dierent person during the course of their psychosis, and
that in their recovery they returned to a previous sense of self, although some felt that parts of their
previous identity were still missing upon this return. Participants diered in whether their psychotic
experiences were meaningful or meaningless to their self-understanding, and some struggled to reconcile
these two possibilities, holding both in conjunction. Many participants felt that their self-understanding had
been improved due to their experience of psychosis, whereas others still felt unable to understand the
meaning of their experiences. Participants spoke of a variety of responses to the diagnoses and explana-
tions oered to them at the EIS, rejecting them, embracing them, and sometimes struggling to incorporate
them into their own view of what had happened. Many participants described positive changes to their
identity, including greater maturity, empathy, compassion, and appreciation, following their experience of
psychosis. Below, we consider three topics that these results bring to the fore in greater detail.
Recovery styles: integrating versus sealing-over
In this study, the importance of participant’s psychotic experiences to their self-understanding varied. Some
participants described psychosis as “crucial” to their self-understanding or as helping them recognize
a trauma they’d been carrying with them for a long time. Others described psychosis as a time in which “I
left myself and then I came back” or as something that “postponed” their identity, but that hadn’t changed
them. These dierences are similar to the distinction between integrating and sealing over introduced
above, in which individuals either attempt to understand their experiences of psychosis as meaningful or
try to put them behind them without examining them (Levy et al., 1975; McGlashan et al., 1976).
Most of the participants in this study emphasized that they felt they had greater self-understanding as
a result of their experience of psychosis, but many also felt that they were not themselves during psychosis.
For example, one participant described the experience of psychosis as a “blip in the road”, but also said that
this experience had revealed to them how being bullied when they were young had aected them in the
long term. Another participant said “I feel separate from that experience” in reference to psychosis, but also
reported that “now I feel I know myself better”. This suggests a mixed-recovery style, in that some
participants were developing meaning and self-understanding from their psychotic experiences, or
integrating, but also tended to view the experience of psychosis as distinct from themselves, suggesting
sealing-over. This indicates that perhaps a more ne-grained analysis of recovery styles would be useful, in
order to better capture the complexity and diversity of experiences of psychosis. These experiences also
could be understood in terms of two phases of recovery that Connell et al. (2015) have called self-
estrangement and self-consolidation, in which some participants rst distance themselves from their
experience and later make sense of it and, in doing so, forge a stronger self.
PSYCHOSIS 7
Psychosis and post-traumatic growth
One particularly pronounced nding was the frequency with which participants reported positive changes
to their identity following psychosis. Participants described a variety of changes: becoming more mature,
gaining a sense of appreciation, developing more empathy and compassion for others experiencing
distress, becoming less critical of themselves, developing goals and priorities they had not had before,
and becoming more condent and positive. These ndings replicate previous research that has found
similar positive changes to individuals following psychosis (Attard et al., 2017; Connell et al., 2015; Jordan
et al., 2019).
This aligns with a growing body of literature documenting how people who have experienced
psychosis see it as an opportunity to change and improve their lives (Eisenstadt et al., 2012; Romano
et al., 2010) as well as the experience of post-traumatic growth (PTG) in the context of recovery from FEP
(Jordan et al., 2019; Mapplebeck et al., 2015; Mazor et al., 2016). Though PTG is increasingly seen as
a component of recovery from psychosis, the process of how PTG occurs is not well understood. In this
study, one participant felt they were “clueless” following the psychosis and when they thought of their past
identity, regretted the things they were no longer able to do. Conversely, another participant spoke of
learning how their psychotic experiences were related to their past life experiences, as well as how the
experience of psychosis helped them to develop more compassion for others and be less critical of
themselves. Though limited by the nature of the data, this suggests that those who favor an integrative
recovery style, in which meaning is found within psychosis, might be more inclined to also experience PTG.
This relates to previous research, which has found that developing a positive, constructive meaning from
one’s experience seems to be important to PTG (Mapplebeck et al., 2015). This suggests that therapeutic
approaches that focus on developing a narrative and integrating one’s self, including Drama Therapy and
Dance Movement Therapy, may be useful if adapted for the treatment of FEP (Armstrong et al., 2016;
Pierce, 2014).
Explanatory frameworks: developing a bricolage
Participants in this study used a variety of explanatory frameworks to understand their experiences
of psychosis. Some adopted biomedical frameworks, describing psychosis as an “illness”, while
others saw their experiences as spiritual, or as connected to past experiences or self-esteem. Many
used multiple explanatory frameworks to understand their experiences, describing psychosis as “a
chemical reaction in my brain” but also “crucial” to their self-understanding.
Individuals use of multiple explanatory frameworks to understand their experience of psychosis has
previously been examined. In other studies, some participants framed their experiences using a biomedical
explanatory framework (Macnaughton et al., 2015)
1
, but others developed syncretic explanations incorpor-
ating elements of both biomedical and other explanatory frameworks, incorporating elements of culturally
specic beliefs (Islam et al., 2015), spirituality (Jones et al., 2016; Macnaughton et al., 2015), and psychosocial
elements (Dudley et al., 2009). This has been described as a process of engaging in “bricolage„, involving
the “innovative and creative conceptual work to appropriate and combine dierent explanations to make
sense of their individual situations and experiences” (Corin, 1998; Larsen, 2004).
The development of a personally meaningful explanation for one’s experiences has also been
described as narrative insight (Marriott et al., 2019). Roe and Davidson (2005) suggest that this “re-
authoring” of one’s life story should be seen as a core component of recovery. Others emphasize the
importance of recognizing what went wrong and reconciling this with one's self-understanding, as
well as rebuilding one's identity and reconstructing one's world view after an experience of psychosis
(Perry et al., 2007; Windell et al., 2012). Further, exploring personal narratives can be important to
developing and maintaining therapeutic alliances (Lysaker et al., 2009).
In this study, the explanations oered by health-care professionals were sometimes appreciated by
participants, some of whom found solace in the distance between self and illness that the term “psychosis”
creates, while others struggled to nd meaning in explanation involving the brain or the inuence of family
8P. FRIESEN ET AL.
members. Other participants questioned whether the term “psychosis” or “serious mental illness” applied
to them. This aligns with ndings from Berkhout and colleagues (2019), in which clinical encounters within
EIS were sometimes found to complicate experiences of self and understanding. As the authors describe it,
“when the context and meaning of psychosis and self were not understood or appreciated in clinical
settings, further self-experience was disrupted” (2019, p. 456). This reects previous research reporting how
many people treated for psychosis feel that the biomedical explanatory framework prevalent in clinical
services failed to explain their experiences and that they must develop personal meanings of their
experiences on their own (Jones & Shattell, 2016; Macnaughton et al., 2015). This suggests that providers
can play an important role in supporting self-exploration and that further research regarding how best to
support to individuals engaging in bricolage in EIS may be worthwhile.
Limitations
This was a qualitative, exploratory study. As a result, the sample was small and the results should not be
taken as broadly generalizable. The participants were diverse in terms of race, ethnicity, and cultural
background, but were all enrolled in an EIS in a large, urban city, and so may not be reective of those in
other settings. The interviews took place in the same building that the participants received care in, which
could have inuenced their responses, if they associated the interview setting with their care setting, even
though it was made clear during the consent process that none of their responses would be shared with
their providers or impact their care. The incentive that was oered hopefully helped to recruit a variety of
participants and not only those hoping to share a favourable experience.
Conclusion
Interviews with individuals enrolled in an EIS revealed that participants’ identities were impacted by their
experiences of psychosis in a variety of ways. Some participants felt both that these experiences were
distinct from themselves and several thought that they were meaningful to their self understanding. Many
felt that, after their experiences of psychosis, they had returned to their previous self, although some felt
there were still part of themselves missing. Many experienced positive changes to their identities following
psychosis, suggestive of post-traumatic growth. Participants also engaged in bricolage, utilizing a variety of
explanatory frameworks, such as biomedical, spiritual, and psychosocial frameworks, to describe and
understand their experiences of psychosis.
Note
1. Biomedical explanations of psychosis have been observed to be protective, in that they can reduce feelings of
responsibility for one's experiences, but this can be a double-edged sword, in that such explanations can also
reduce the agency individuals feel with regards to their recovery (Lam et al., 2011; Lysaker et al., 2009).
Acknowledgements
A number of people oered their time and guidance in support of this research and the development of the manuscript.
Thank you to Anne Skrobala, Sarah Piscitelli, Sacha Zilkha, Ryan Lawrence, Sascha DuBrul, Morgan Haselden, PJ
Williamson, Nannan Liu, Yael Holoshitz, Loren Dent, Beth Broussard, and Matthew Peters.
Disclosure of Interest
The authors have no conicts of interest to report.
PSYCHOSIS 9
Disclosure statement
No potential conict of interest was reported by the authors.
Funding
This work was supported by a doctoral scholarship from the Social Sciences and Humanities Research Council of Canada
(752-2015-0433) and a Dr. Louise Lennihan Arts & Sciences Grant from the Futures Initiative of the CUNY Graduate
Center.
References
Armstrong, C. R., Rozenberg, M., Powell, M. A., Honce, J., Bronstein, L., Gingras, G., & Han, E. (2016, July). A step toward
empirical evidence: Operationalizing and uncovering drama therapy change processes. The Arts in Psychotherapy, 49,
27–33. https://doi.org/10.1016/j.aip.2016.05.007.
Attard, A., Larkin, M., Boden, Z., & Jackson, C. (2017). Understanding adaptation to rst episode psychosis through the
creation of images. Journal of Psychosocial Rehabilitation and Mental Health, 4(1), 73–88. https://doi.org/10.1007/
s40737-017-0079-8.
Ben-David, S., & Kealy, D. (2020). Identity in the context of early psychosis: A review of recent research. Psychosis, 12(1),
1–11. https://doi.org/10.1080/17522439.2019.1656283.
Berkhout, S. G., Zaheer, J., & Remington, G. (2019). Identity, subjectivity, and disorders of self in psychosis. Culture,
Medicine and Psychiatry, 43(3), 442–467. https://doi.org/10.1007/s11013-019-09631-y.
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101.
https://doi.org/10.1191/1478088706qp063oa.
Connell, M., Schweitzer, R., & King, R. (2015). Recovery from rst-episode psychosis and recovering self: A qualitative
study. Psychiatric Rehabilitation Journal, 38(4), 359–364. https://doi.org/10.1037/prj0000077.
Corin, E. (1998). The thickness of being: Intentional worlds, strategies of identity, and experience among schizophrenics.
Psychiatry, 61(2), 133–146. https://doi.org/10.1080/00332747.1998.11024824.
Davidson, L. (2003). Living Outside Mental Illness: Qualitative Studies of Recovery in Schizophrenia. NYU Press.
de Jager, A., Rhodes, P., Beavan, V., Holmes, D., McCabe, K., Thomas, N., McCarthy-Jones, S., Lampshire, D., & Hayward, M.
(2016). Investigating the lived experience of recovery in people who hear voices. Qualitative Health Research, 26(10),
1409–1423. https://doi.org/10.1177/1049732315581602.
Deegan, P. E. (1997). Recovery and empowerment for people with psychiatric disabilities. Social Work in Health Care, 25
(3), 11–24. https://doi.org/10.1300/J010v25n03_02.
Dudley, R., Siitarinen, J., James, I., & Dodgson, G. (2009). What do people with psychosis think caused their psychosis?
A Q methodology study. Behavioural and Cognitive Psychotherapy, 37(01), 11. https://doi.org/10.1017/
S1352465808004955.
Eisenstadt, P., Monteiro, V. B., Diniz, M. J. A., & Chaves, A. C. (2012). Experience of recovery from a rst-episode psychosis:
Recovery from a rst-episode psychosis. Early Intervention in Psychiatry, 6(4), 476–480. https://doi.org/10.1111/j.1751-
7893.2012.00353.x.
Estro, S. E. (1989). Self, identity, and subjective experiences of schizophrenia: In search of the subject. Schizophrenia
Bulletin, 15(2), 189–196. https://doi.org/10.1093/schbul/15.2.189.
Gergel, T., & Iacoponi, E. (2017). Psychosis and identity: Alteration or loss? Journal of Evaluation in Clinical Practice, 23(5),
1029–1037. https://doi.org/10.1111/jep.12768.
Hirschfeld, R., Smith, J., Trower, P., & Grin, C. (2005). What do psychotic experiences mean for young men? A qualitative
investigation. Psychology and Psychotherapy: Theory, Research and Practice, 78(2), 249–270. https://doi.org/10.1348/
147608305X25865.
Islam, Z., Rabiee, F., & Singh, S. P. (2015). Black and minority ethnic groups’ perception and experience of early
intervention in psychosis services in the United Kingdom. Journal of Cross-cultural Psychology, 46(5), 737–753.
https://doi.org/10.1177/0022022115575737.
Iyer, S., Jordan, G., MacDonald, K., Joober, R., & Malla, A. (2015). Early intervention for psychosis: A canadian perspective.
The Journal of Nervous and Mental Disease, 203(5), 356–364. https://doi.org/10.1097/NMD.0000000000000288.
Jones, N., Kelly, T., & Shattell, M. (2016). God in the brain: Experiencing psychosis in the postsecular United States.
Transcultural Psychiatry, 53(4), 488–505. https://doi.org/10.1177/1363461516660902.
Jones, N., & Shattell, M. (2016). Not what the textbooks describe: Challenging clinical conventions about psychosis.
Issues in Mental Health Nursing, 37(10), 769–772. https://doi.org/10.1080/01612840.2016.1180725.
Jordan, G., MacDonald, K., Pope, M. A., Schorr, E., Malla, A. K., & Iyer, S. N. (2018). Positive changes experienced after a rst
episode of psychosis: A systematic review. Psychiatric Services (Washington, D.C.), 69(1), 84–99. https://doi.org/
10.1176/appi.ps.201600586.
10 P. FRIESEN ET AL.
Jordan, G., Malla, A., & Iyer, S. N. (2019, July 15). “It’s brought me a lot closer to who i am”: A mixed methods study of
posttraumatic growth and positive change following a rst episode of psychosis. Frontiers in Psychiatry, 10, 480.
https://doi.org/10.3389/fpsyt.2019.00480.
Lam, M. M. L., Pearson, V., Ng, R. M. K., Chiu, C. P. Y., Law, C. W., & Chen, E. Y. H. (2011). What does recovery from psychosis
mean? perceptions of young rst-episode patients. International Journal of Social Psychiatry, 57(6), 580–587. https://
doi.org/10.1177/0020764010374418.
Larsen, J. A. (2004). Finding meaning in rst episode psychosis: Experience, agency, and the cultural repertoire. Medical
Anthropology Quarterly, 18(4), 447–471. https://doi.org/10.1525/maq.2004.18.4.447.
Levy, S. T., McGlashan, T. H., & Carpenter, J. W. (1975). Integration and sealing-over as recovery styles from acute
psychosis. The Journal of Nervous and Mental Disease, 161(5), 307–312. https://pubmed.ncbi.nlm.nih.gov/1185151/
Lysaker, P., Yanos, P. T., & Roe, D. (2009). The role of insight in the process of recovery from schizophrenia: A review of
three views. Psychosis, 1(2), 113–121. https://doi.org/10.1080/17522430902948175.
Macnaughton, E., Sheps, S., Frankish, J., & Irwin, D. (2015). Understanding the development of narrative insight in early
psychosis: A qualitative approach. Psychosis, 7(4), 291–301. https://doi.org/10.1080/17522439.2014.980306.
Mapplebeck, C., Joseph, S., & Sabin-Farrell, R. (2015). An interpretative phenomenological analysis of posttraumatic growth
in people with psychosis. Journal of Loss & Trauma, 20(1), 34–45. https://doi.org/10.1080/15325024.2013.821375.
Marriott, M. R., Thompson, A. R., Cockshutt, G., & Rowse, G. (2019). Narrative insight in psychosis: The relationship with
spiritual and religious explanatory frameworks. Psychology and Psychotherapy: Theory, Research and Practice, 92(1),
74–90. https://doi.org/10.1111/papt.12178.
Mazor, Y., Gelkopf, M., Mueser, K. T., & Roe, D. (2016, December 19). Posttraumatic growth in psychosis. Frontiers in
Psychiatry, 7, 202. https://doi.org/10.3389/fpsyt.2016.00202.
McGlashan, T. H. (1987). Recovery style from mental illness and long-term outcomes. The Journal of Nervous and Mental
Disease, 175(11), 681–685. https://doi.org/10.1097/00005053-198711000-00006
McGlashan, T. H., Docherty, J. P., & Siris, S. (1976). Integrative and sealing-over recoveries from schizophrenia:
Distinguishing case studies. Psychiatry, 39(4), 325–338. https://doi.org/10.1080/00332747.1976.11023903.
McGrath, J. J., Saha, S., Al-Hamzawi, A. O., Alonso, J., Andrade, L., Borges, G., Bromet, E. J., Oakley Browne, M.,
Bruaerts, R., de Almeida, C., Fayyad, J. M., Florescu, J., de Girolamo, S., Gureje, G., Hu, O., de Jonge, C., Kovess-
Masfety, P., Lepine, V., Lim, J. P., & Kessler, R. C., & . (2016). Age of onset and lifetime projected risk of psychotic
experiences: Cross-national data from the world mental health survey. Schizophrenia Bulletin, 42(4),933–941. https://
doi.org/10.1093/schbul/sbw011.
Noiseux, S., & Ricard, N. (2008). Recovery as perceived by people with schizophrenia, family members and health
professionals: A grounded theory. International Journal of Nursing Studies, 45(8), 1148–1162. https://doi.org/10.1016/
j.ijnurstu.2007.07.008.
Nolin, M., Malla, A., Tibbo, P., Norman, R., & Abdel-Baki, A. (2016). Early intervention for psychosis in Canada: What is the
state of aairs? Canadian Journal of Psychiatry. Revue Canadienne De Psychiatrie, 61(3), 186–194. https://doi.org/
10.1177/0706743716632516.
Perry, B. M., Taylor, D., & Shaw, S. K. (2007). “You’ve got to have a positive state of mind”: An interpretative
phenomenological analysis of hope and rst episode psychosis. Journal of Mental Health, 16(6), 781–793. https://
doi.org/10.1080/09638230701496360.
Pierce, L. (2014). The integrative power of dance/movement therapy: Implications for the treatment of dissociation and
developmental trauma. The Arts in Psychotherapy, 41(1), 7–15. https://doi.org/10.1016/j.aip.2013.10.002.
Roe, D., & Davidson, L. (2005). Self and narrative in schizophrenia: Time to author a new story. Medical Humanities, 31(2),
89–94. https://doi.org/10.1136/jmh.2005.000214.
Romano, D. M., McCay, E., Goering, P., Boydell, K., & Zipursky, R. (2010). Reshaping an enduring sense of self: The process
of recovery from a rst episode of schizophrenia: First episode schizophrenia recovery. Early Intervention in Psychiatry,
4(3), 243–250. https://doi.org/10.1111/j.1751-7893.2010.00187.x.
Staring, A. B. P., van der Gaag, M., & Mulder, C. L. (2011). Recovery style predicts remission at one-year follow-up in
outpatients with schizophrenia spectrum disorders. The Journal of Nervous and Mental Disease, 199(5), 295–300.
https://doi.org/10.1097/NMD.0b013e3182174e97.
Tait, L., & Birchwood, M., & Petertrower. (2004). Adapting to the challenge of psychosis: Personal resilience and the use of
sealing-over (avoidant) coping strategies. British Journal of Psychiatry, 185(5), 410–415. https://doi.org/10.1192/bjp.
185.5.410
Tedeschi, R. G., & Calhoun, L. G. (2004). Posttraumatic Growth: Conceptual Foundations and empirical evidence.
Psychological Inquiry, 15(1), 1–18. https://doi.org/10.1207/s15327965pli1501_01.
Thompson, K. N., McGorry, P. D., & Harrigan, S. M. (2003). Recovery style and outcome in rst-episode psychosis.
Schizophrenia Research, 62(1–2), 31–36. https://doi.org/10.1016/S0920-9964(02)00428-0.
Windell, D., Norman, R., & Malla, A. K. (2012). The personal meaning of recovery among individuals treated for a rst
episode of psychosis. Psychiatric Services, 63(6), 548–553. https://doi.org/10.1176/appi.ps.201100424.
PSYCHOSIS 11
