BRIEF REPORTS

Investigation of Insight Formation Using Narrative Analyses

of People With Schizophrenia in Remission
Nai-Ying Ko, RN, PhD,* Ming-Li Yeh, MS,† Su-Ting Hsu, MD, ScD,‡ Hsin-Hsin Chung, MS,§
and Cheng-Fang Yen, MD, PhD储

toms, its social consequences, or the need for treatment. This

Abstract: Poor insight in schizophrenic patients is a common and
multidimensional phenomenon. The purpose of this study was to
explore the process of the formation of insight in patients with
schizophrenia in remission. A qualitative design was used to analyze
first-person narratives of 50 people with schizophrenia in remission.
Face to face, semistructured interviews were conducted by investi-
gators, and the narratives were transcribed verbatim. The results of
our study showed that there were four stages of illness understand-
ing in patients with schizophrenia: 1) the feeling that symptoms
were unbearable or a loss of control, 2) comparisons of experiences
with references, 3) perception that medication was working through
trial and error experiments, and 4) awareness of illness after medi-
cation relieved symptoms. Insight formation is an active process in
which schizophrenic patients gain knowledge about their medica-
tion, connect the association between their medication and symp-
toms, and realize they need to deal with issues.
Key Words: Schizophrenia, insight, narrative analysis.
(J Nerv Ment Dis 2006;194: 124 –127)
I nsight in schizophrenic patients is understood today as a
multidimensional and continuous form of psychopathology
(Amador et al., 1991; David, 1990). Researchers have re-
vealed that lack of insight may compromise treatment com-
pliance and clinical outcomes for schizophrenic patients (Lin
et al., 1979; McEvoy et al., 1989; Schwartz et al., 1997; Yen
et al., 2002). However, many patients with schizophrenia do
not have awareness of the nature of the disorder, its symp-
*School of Medicine, Department of Nursing, National Cheng Kung Uni-
versity, Tainan City, Taiwan; †Department of Nursing, Oriental Institute
of Technology, Taipei County, Taiwan; ‡Department of Psychiatry,
Kaohsiung Chang-Gang Hospital, Kaohsiung County, Taiwan; §School
of Nursing, Kaohsiung Medical University, Kaohsiung City, Taiwan;
㛳Department of Psychiatry, College of Medicine, Kaohsiung Medical
University, Kaohsiung City, Taiwan; and ¶Department of Psychiatry,
Kaohsiung Medical University and Chung-Ho Memorial Hospital,
Kaohsiung City, Taiwan.
Supported by a grant (NSC 87-2413-H-037-006) from the National Science
Council, Taiwan.
Send reprint requests to Cheng-Fang Yen, MD, PhD, Department of Psy-
chiatry, Kaohsiung Medical University, No. 100 Tzyou 1st Rd., Kaohsi-
ung City, Taiwan 807.
Copyright © 2006 by Lippincott Williams & Wilkins
ISSN: 0022-3018/06/19402-0124
DOI: 10.1097/01.nmd.0000198197.56497.44
lack of awareness of one’s own illness could increase the burden
on caregivers as well as jeopardize the treatment partnership
between the patients and mental health professionals.
During the past few decades, most researchers have
focused on the conceptualization and assessment of insight
(Amador and Strauss, 1993; David et al., 1992) and its relation-
ships with psychopathology (Amador and David, 1998; Ama-
dor et al,. 1994; Mintz et al., 2003; Sevy et al., 2004) and
neuropsychological impairment (David et al., 1995; Lysaker
et al., 1998; McEvoy et al., 1993; Young et al., 1998) among
patients with schizophrenia. A longitudinal study has re-
ported that insight into past episodes improved over time in
patients with schizophrenia (Cuesta et al., 2000). Previous
qualitative studies only focused on the interpretation of psy-
chotic symptoms (Casey and Long, 2002; Sacks et al., 1974).
We know of no study that has explored the processes of
insight formation among schizophrenic patients. Moreover,
insight is often judged in relation to the beliefs of clinical
experts, and less attention has been paid to how people with
schizophrenia make sense of their experience of the illness in
terms of the process of insight formation. The main criticism
of this approach has been that it fails to account for patients’
perceptions of the illness, which is implicitly embedded
within a personal narrative. The study of patients’ narratives
offers the possibility of developing an understanding about
how and in what way the patients know they are ill. Under-
standing the process of insight formation is a more positive
perspective on illness experience, rather than merely empha-
sizing the failure to recognize symptoms or inability to
identify the experience as illness. A meta-analysis indicated
that psychopathology was related to insight and that the acute
stage would influence the relationship between insight and
symptoms (Mintz et al., 2003). To understand the processes
of insight formation, it is appropriate to interview schizo-
phrenic patients in remission without symptom interference.
Thus, the aim of this study was to explore the process of
insight formation into the illness through analyzing personal
narratives among people with schizophrenia in remission.
METHODS
Narrative analysis is an interpretive process of making
sense. Contrasted with a more individualistic cognitive con-
struction of reality in most phenomenological analyses, nar-
rative analysis was created from first-person accounts of a

124 The Journal of Nervous and Mental Disease • Volume 194, Number 2, February 2006
The Journal of Nervous and Mental Disease • Volume 194, Number 2, February 2006
narrator in conjunction with a researcher as a listener and was
based on the supposition that the person was engaged in
making sense of the illness experience by telling stories about
his or her experiences (Riessman, 1993). In this study, a
qualitative design using narrative analysis was employed to
analyze first-person narratives of schizophrenic people de-
pending on their insight into the illness during the disease
trajectory.
We enrolled 50 schizophrenic patients (26 men and 24
women) in remission from outpatient psychiatric settings and
the rehabilitative psychiatric ward of a medical center (N ⫽
28) and a mental hospital (N ⫽ 22) in southern Taiwan. They
had a mean age of 31.6 years (SD ⫾ 7.3) and a mean
education of 11.1 years (SD ⫾ 2.6). They received the diagnosis
of schizophrenia according to the DSM-IV (American Psychi-
atric Association, 1994) and had a mean duration of illness of
9.2 years (SD ⫾ 5.8). Their mean scores of any one of three
subscales of the Positive and Negative Syndrome Scale
(Cheng et al., 1996; Kay, 1991) ranged from 1 to 2, which
indicated that all of them were in remittance.
After signing informed consent forms, each participant
received a semistructured interview. For the first five partic-
ipants, a psychiatrist and two psychiatric nurses interviewed
each participant at the same time to increase inter-interviewer
reliability. Then rest of participants was interviewed by one
of three interviewers. Participants were guided by interview-
ers to elucidate 1) their past experiences that resulted in
hospitalization or visiting outpatient service units, 2) their
understandings and views about those experiences, 3) whether
they viewed their problems as an illness, and 4) if so, how and
in what ways they knew they were ill. Each interview lasted
for 60 to 90 minutes. All interviews were tape-recorded and
transcribed verbatim. Interviewers also rated the level of
insight for each participant using the Schedule of Assessment
of Insight (SAI; David, 1990). The full score of SAI is 14,
with higher SAI scores indicating greater insight. For the
purposes of analysis, the participants were further divided
into three groups according to their SAI scores: 18 partici-
pants with intact insight (SAI score: 10 –14), 17 with mod-
erate insight (SAI score: 5–9), and 15 with impaired insight
(SAI score: 0 – 4).
All of the audiotaped transcriptions were coded and
analyzed using the qualitative data analysis package ATLAS.
Narratives of participants with intact insight were analyzed
first, and the themes generated were used to analyze the
narratives of other participants. We used the Riessman (1993)
approach of narrative analysis to analyze data for this study.
At the essential first step, each narrative was read through
several times in an attempt to grasp the sense of how people
with schizophrenia make sense of their illness. Second, five
structural features of each narrative were identified: 1) pro-
viding an abstract for what follows, 2) orienting the listener,
3) carrying the complicating action, 4) evaluating its mean-
ing, and 5) resolving the action. Third, core narrative themes
were reduced and identified from the narratives. Fourth, the
themes identified for commonalties were grouped together by
order and sequence. During the final stage, a coherent story
was constructed to describe how people with schizophrenia
© 2006 Lippincott Williams & Wilkins
Insight Formation in Schizophrenics
make sense of their illness in terms of the process of forming
insight into the illness throughout their disease trajectory.
Four criteria proposed by Riessman (1993) were used
for ensuring validation of narrative analysis: 1) the interpre-
tation was reasonable and convincing, 2) the analyst’s recon-
structions and interpretations of the subjects’ narratives were
recognizable as adequate representations, 3) the interpreta-
tions were coherent, and 4) there was pragmatic use of the
information for future studies. The first author took primary
responsibility for the analyses independently, and other au-
thors evaluated and enhanced the study.
RESULTS
The process of schizophrenic patients making sense of
their illness can be categorized into four stages: 1) feeling that
symptoms are unbearable or a loss of control, 2) comparisons
of experiences with references, 3) perception that medication
works through trial and error experiments, and 4) awareness
of illness after medication relieves symptoms. All 18 partic-
ipants with intact insight went through the four stages of
insight formation to make sense of the illness. Participants
with moderate insight experienced the initial one or two
stages of insight formation but failed to follow through with
the remaining stages. Contrary to the participants with intact
or moderate insight, participants with impaired insight ratio-
nalized their past experience of psychiatric hospitalization or
outpatient visits and did not feel that symptoms were unbear-
able. They did not show clear stages with regard to insight
into their psychotic experiences.
Feeling That Symptoms Are Unbearable or a
Loss of Control
The patient’s endurance of their symptoms was an
essential milestone in insight formation. Before the first
hospitalization or visiting outpatient service units, many pa-
tients had suffered from symptoms for a long period of time.
The most frequent unbearable symptoms were nonspecific
symptoms, such as insomnia, irritable mood, and feeling out
of control. They were not aware that those symptoms might
be strange or even psychotic unless those symptoms influ-
enced their daily life or social functions. Only one participant
in the study reported that his symptoms, the feeling of vertigo
and smelling odd odors, were unbearable during the first
episode of the illness; otherwise, most of participants tried to
endure the symptoms for a period of time before seeking
professional help. They noticed that “something was wrong
with them” when they felt they could not tolerate them
anymore. One of the participants described her experience of
feeling that “something was wrong” as follows:
“When I was in the second year of senior high school,
my situation became even worse. I heard voices when I was
riding my bicycle. I saw ghosts and someone hanging around.
I was living in fear. I told my father that I felt something was
wrong with me. I was always tired since the chaotic ideas that
were implanted in my head were spinning around. I fell
asleep as soon as I came home and did not eat much.”
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Ko et al. The Journal of Nervous and Mental Disease • Volume 194, Number 2, February 2006
Comparisons of Experiences With References
Participants often took time to figure out the fact that their
strange experiences did not happen to others. If they could use
the experiences of others and of themselves prior to the episodes
as references, they finally realized that they were somewhat
different and knew “something was wrong with them.” For
example, one patient recognized her hallucinations after asking
her family members about their experiences:
“I often heard voices that would amuse me and won-
dered how it could be like that. I asked my family members
whether they had similar experiences, but they said they did
not hear anything.”
Some participants found their experiences were unusual
when they saw other patients that behaved like them during
hospitalization. For example, one patient recognized his ill-
ness after comparing his behaviors with others:
“At the beginning, I did not think I was 关schizophrenic兴.
After hospitalization and having treatment, I feel I am grad-
ually recovering. . . . It seems like I did have that kind of
problem. . . . I saw that those patients around me were un-
stable when they were first admitted to the hospital. After
taking mediation, which is similar to the medication I had
taken, their behaviors became normal again. . . . After a
while, I came to know more and more volunteers and new
patients, and after being with them, I finally realized that they
were in same situation I was.”
Patients also felt they were sick once they could not
function as well as they usually did. One patient described how
she was aware of her illness due to her memory impairment:
“I was doing fine in my academic performance when I
was in senior high school. I do not know why I could not
memorize the contents of books I read afterward. I was
emotionally unstable and was irritated by my teachers and
classmates at that time. . . . I felt I got sick. I used to be able
to understand the context of television programs quickly.
However, recently, everything has slowed down. When I
watch a television program, it is too fast for me to understand
what the people were saying . . ..”
Perception That Medication Works Through
Trial and Error Experiments
The patients’ insight into illness was formulated when
they perceived that the medication could help them back to
normal referring to alleviate the unbearable symptoms. How-
ever, most patients tried to stop taking their medications after
they felt the symptoms were gone. Once they stopped taking
the medication, they found that the symptoms would return.
Yet those returning symptoms would be alleviated after
taking the medication again. The trial and error experiments
reinforced the patients’ beliefs that they were ill and treat-
ments did really work:
“Now I know that taking medication is necessary. . . . I
did not know that at the very beginning. . . . I thought I would
be okay after taking the medication for a while. I did not want
to continue taking medication for a long time . . . After I
stopped taking the medication, a while later, the illness came
back. I found that the medication did help. It helped me stabilize
my mood, and then I could get to sleep. My emotions are
stable . . . I do not feel unhappy all the time. . . ..”
126
Awareness of Illness After Medication
Relieves Symptoms
A majority of patients described that they knew their
diagnosis from their medical certificates or the diagnosis
shown on their medical records. However, the acknowledg-
ment and description of the diagnosis of schizophrenia did
not necessarily lead patients to identify themselves as suffer-
ers of such an illness. The patients’ insights into the illness
had not implanted in their minds unless they had linked the
diagnosis with their unbearable symptoms that could be
alleviated by medication:
“The medication really helps me to control my moods.
I used to feel explosive. I wanted to go out and kill myself.
The medication calmed me down, both my behaviors and my
temper. . . . I feel like I can accept my thoughts. I do not rush
out of my home after taking medication. . . . I do not hear
voices anymore. I feel like I am a patient. I will take
medicine. I have schizophrenia and have to take medicine;
otherwise I would kill myself or to do something I should
never do.”
DISCUSSION
This study explored the process of insight formation
through analyzing personal narratives among patients with
schizophrenia. In his work on the issue of insight, Lewis
(1934) indicated that insight was concerned primarily with
the awareness of change and secondarily with the judging of
this change. Experience of illness had been characterized in
part by a two-way distinction: experienced different both
from things that we do and from things that are done or
happen to us (Fulford, 1998). In this study, we found that
schizophrenic patients might not consider their symptoms to
be something wrong until they could not tolerate them any-
more. According to this framework, clinical workers should
first listen empathetically to these patients’ personal accounts
of their psychiatric experiences, and figure out which stage of
insight the patient is in. Through feedback, interpretation, and
education, clinical workers can help them be aware of their
dissatisfactions of everyday life and connect those with their
symptoms (Prochaska, 2000). Once patients make the con-
nections between symptoms and life experiences, clinical
workers can trigger the initiation of formation of insight by
encouraging them to contemplate thoroughly the possible
etiology of the intolerable symptoms.
In this study, we also found that after perceiving their
unbearable experiences, patients tried to compare their cur-
rent situations with others and also did self-comparison with
who they were, and finally realized that they were somewhat
different from others. Comparison of their current situations
with past situations of themselves and that of others is one
kind of neurocognitive function. Poor insight significantly
correlated with neuropsychological impairment of frontal
lobe among schizophrenic patients (Lysaker et al., 1998;
Young et al., 1998), which might partially explain why some
schizophrenic patients develop the comparisons and realize
their differences; however, some schizophrenic patients per-
sistently deny their differences.
© 2006 Lippincott Williams & Wilkins
The Journal of Nervous and Mental Disease • Volume 194, Number 2, February 2006
Even having perceived that something wrong is occur-
ring, schizophrenic patients might still feel ambivalent to-
ward being in a situation for which medication is considered
necessary. Moore et al. (1979) proposed the notion of “dis-
positional shift,” an elaboration of attribution theory, which
notes that there is a shift from a situational to a dispositional
attribution about the self that occurs over time in an individ-
ual following a key event or experience. In this study, the
patients’ insights into illness were formulated when they
perceived the treatment could help them return to normal, that
is to alleviate the unbearable symptoms. Patients usually
underwent the trial and error period to resolve their symp-
toms. Then they might be aware they had a continuing
problem as they consistently found medication relieving their
symptoms (stage 3). From this framework, adequate treat-
ment of the symptoms that patients suffer from and discus-
sion with them about the benefits of treatment will be bene-
ficial to the formation of insight into the illness. Moreover,
clinical workers’ feedback and discussions with patients
about their repeated experiences of relieving symptoms by
medication may maintain their intact insight.
Lally (1989) used the term “engulfment” to illustrate the
process of insight formation. He emphasized the subjective and
intrapsychic aspect of this interactive societal self-stigmatizing
process and designated how the process of insight in the form of
labeling one’s self with a psychiatric diagnosis may be harmful.
However, in this study, we revealed that some schizophrenic
patients confirmed their mental illnesses through perceiving the
effects of the medication that relieved their unbearable symp-
toms. It is an active process in which patients are aware of their
illnesses through connecting the association between medication
and symptoms. The process of insight formation may not be
necessarily as pessimistic as the course of self-stigmatizing or
self-engulfment.
One of the limitations in this study was that the inter-
pretation of the findings may not be useful when generalizing
about patients who refuse medical treatment. Another possi-
ble limitation derives from the doubt whether the validity of
the narrative data collected from schizophrenic patients’ first-
person accounts as direct reflections of their experiences is
reliable. However, the study by Lysaker et al. (2002) con-
firmed the validity of schizophrenic patients’ narrative ac-
counts, and the coherence significantly correlated with insight
among schizophrenic patients. Overall, insight formation is
an active process among schizophrenic patients. Better un-
derstanding of insight formation has implications for mental
health professionals to acknowledge individual efforts in
attempting to restore a sense of order and connection with
others and making sense of their illness experiences.
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