THE IMPACT OF ILLNESS IDENTITY ON RECOVERY FROM SEVERE MENTAL ILLNESS

Supervisor : dr Sabar P Siregar, Sp KJ

American Journal of Psychiatric Rehabilitation, 13: 7393, 2010 Copyright # Taylor & Francis Group, LLC ISSN: 1548-7768 print=1548-7776 online DOI: 10.1080/15487761003756860

INTRODUCTION
The impact of the experience and diagnosis of mental illness on ones identity has long been recognized; however, little is known about the impact of illness identity. The present article proposes a theoretically driven model of the impact of illness identity on the course and recovery from severe mental illness and reviews relevant research.

DEFINITION
the set of roles and attitudes that people have developed about themselves in relation to their understanding of mental illness.

Illness Identity

THE MODEL
No comprehensive theoretical model currently exists of how illness identity impacts important aspects of recovery. The purpose of the present paper is to propose a theoretically driven model of the impact of illness identity on the course of and recovery from severe mental illness and to review the existing empirical research that supports it.

HYPOTHESIS
Illness identity may play a major role in the course of severe mental illness, affecting both subjective and objective outcomes related to recovery.

Cont(1)

the impact of any awareness of having a psychiatric problem is moderated by the meanings that the person attaches to that problem (that is, how the illness is conceptualized and what that means about the person experiencing it). once a person has decided to characterize unusual experiences at least partly as being the result of mental illness, what that illness means about him or her becomes a key issue.

Cont(2)

Illness identity affects hope and self-esteem. Self-esteem refers to the evaluative aspects of the self, or self-regard (Baker & Gallant, 1984). some persons may identify with having a mental illness and ascribe widely-held stigmatizing views to this status, while others may make a similar identification but take on a positive identity by way of identification with peers

 Key of ideas:

Cont(3)

First key:
persons diagnosed with severe mental illness do not merely experience symptoms but they also interpret their experience of having an illness and assign meanings to it which in turn qualify and affect hope and self-esteem.

Second key:
Internalization of these meanings and, in particular, stigma, can infect personal constructions of illness, damaging hope and selfesteem

Cont(4)
influence social interaction lack of hope and low self-esteem may increase depression and create a risk for suicide
the individual to use more avoidant strategies such as removal from anxietyprovoking situations or to use alcohol or drugs to numb unpleasant emotional states.

Hopefullness and self esteem

Cont(5)
the types of coping strategies used can directly affect vocational outcomes, symptom severity, as well as social interaction. the types of coping strategies used, social interactions, and vocational functioning all affect the severity of psychotic symptoms.

Review of Evidence for the Model

General Evidence for Relationship Between Illness Identity and Recovery Relationship Between Illness Identity and Hope/Self-Esteem Impact of Hope and Self-Esteem on Suicide Risk,Coping, and Social Isolation Impact of Hope, Self-Esteem, and Coping on Vocational Outcomes Impact of Coping, Vocational Outcomes, and Social Isolation on Symptoms.

General Evidence for Relationship Between Illness Identity and Recovery

In a series of qualitative studies, described how the process of constructing a new sense of self is an important part of the process of recovery from mental illness. A longitudinal qualitative study, assessing the process of recovery from severe mental illness has supported this conclusion, finding that individuals who improved functioning over a 1year period showed a progression from the identity of patient to person in their narratives, suggesting that maintaining a patient identity can be detrimental to recovery.

Cont(2)

Multiple, quantitative, longitudinal single-case studies have also suggested that as persons progress toward recovery, one of the first steps tends to be the reclamation of a sense of oneself as active agent These studies and those described above suggest that an essential part of the recovery process involves transforming undervalued identities associated with internalized stigma and replacing them with more individualized empowered identities.

Relationship Between Illness Identity and Hope/Self-Esteem Cross sectional studies have found that greater insight is associated with higher levels of dysphoria, lowered self-esteem, and decreased well-being and quality of life. Several studies have also established that there is a relationship between internalized stigma and diminished selfesteem and hope.

Impact of Hope and Self-Esteem on Suicide Risk,Coping, and Social Isolation

There is good support for the relationship between hopelessness and suicide risk among persons with severe mental illness. In the recent review of the predictors of suicidal behavior among people diagnosed with schizophrenia, the researchers identified eight studies finding support for a relationship between hopelessness and suicide risk/behavior among people with schizophrenia.

Cont(2)

Collectively, these findings suggest that diminished hope and self-esteem impact suicidal ideation among people with severe mental illness, and that diminished hope and selfesteem are likely impacted by illness identity factors. A few cross-sectional studies have examined the link between hope/self-esteem and social isolation among persons with severe mental illness.

Cont(3)

In a sample of individuals with recent onset schizophrenia, hopelessness was related to greater social isolation. Self-esteem was positively related to size of the social network and frequency of social interaction.

Impact of Hope, Self-Esteem, and Coping on Vocational Outcomes There is limited evidence for this relationship, as few studies have addressed the relationship between psychological variables and vocational outcomes. More specifically with regard to hope, the researcher found that different dimensions of hopelessness were related to different aspects of subsequent work performance.

Cont(2)

Specifically, loss of motivation was related to poorer social skills and work cooperation, suggesting that individuals who have given up on working as a possibility do not invest the effort in behavior necessary for good job success. The relationship between coping and vocational outcomes has been relatively unstudied

Cont(3) One prospective study (Yau, Chan,Chan, & Chui, 2005), however, found that avoidant coping (depressive resignation) was related to impaired work skills among Clubhouse (Model of Psychosocial Rehabilitation) participants with severe mental illness, and that reductions in avoidant coping over time predicted improvements in work skills. While this study does not necessarily support a relationship between coping and competitive employment, it indicates that coping affects skills related to employment success.

Impact of Coping, Vocational Outcomes, and Social Isolation on Symptoms.

There is evidence supporting all three of these hypothesized relationships. There is cross-sectional evidence that the types of coping strategies typically used by persons with severe mental illness are related to symptom severity The changes in coping strategies were associated with changes in symptom severity over time.

Cont(2)

However, one prospective study, found support that coping may influence symptoms; specifically, the preferences for adaptive coping at baseline predicted fewer psychotic symptoms at follow-up. Strong evidence from studies employing the Experience Sampling Method has found that social interactions with acquaintancesand family members are associated with reductions in the experience of delusions

Cont(3)

Similar findings were not observed for hallucinations,however, suggesting that social interaction might reduce the intensity of some types of symptoms but not others.

Integrative Studies
One recent study A path analysis supported (Yanos, Roe, Markus, the hypothesis that internalized stigma & Lysaker, 2008) has affected avoidant coping, attempted to active social avoidance, conduct an depressive symptoms, integrated study of and that these some of the relationships were mediated by hope and relationships self-esteem. discussed above.
There was also evidence that internalized stigma affects positive symptom severity by way of its impact on social avoidance, but a predicted relationship between avoidant coping and symptom severity was not supported.

Limitations of the existing evidence & recommendations for future research

In some areas, such as hope/self-esteem and employment, research has been mainly either exploratory or crosssectional.

More prospective research is needed to address many of the areas that have been discussed

There is a need for research to test multiple facets of the model in an integrated fashion

DISCUSSION
Evidence in support of the proposed model suggests that ignoring the importance of illness identity may lead to difficult roadblocks in treatment and rehabilitation for many persons with severe mental illness. The proposed model demonstrates how illness identity appears to be a crucial and central intersection influencing various domains of recovery directly, as well as indirectly, through mediating processes.

Cont(2)

If illness identity has such important effects, the question is raised: how can the illness identity of people with severe mental illness be transformed to facilitate recovery?

Cont(3)

The researchers believe that treatment specifically focused on illness identity can have a positive effect on outcomes in this area and can allow persons with severe mental illness to benefit from other high-quality services. Specifically,the cognitive-behavioral therapy (CBT) approaches focused on addressing attitudes related to illness identity can have a favorable impact in this regard.

Cont(4) Helping individuals recover their identity would address self-stigmatizing views as cognitive distortions or dysfunctional attitudes. Experiencing and perceiving oneself differently in relation to stressors and the sense of threat or suffering they generate.

CognitiveBehavioral Therapy (CBT) CBT techniques such as psychoeducation,teaching skills to conduct cognitive, and exposure may all be used to address internalized stigma.

Coping techniques may also be helpful in facilitating a process of constructing and negotiating meanings

Cont(5)

Narrative enhancement
Helping those with The goal of such a severe mental illness process would be to to accept themselves help clients tell more as sufficiently coherent stories about privileged to construct their lives in which and develop a their role as a meaningful story of protagonist is ones self developed

Summary
The researchers have offered a model of how a collection of social, psychological, and clinical forces may interact to create substantial barriers to recovery. They also suggested that to begin with a definition of oneself as mentally ill and to assume that mental illness means incompetence and inadequacy, places people at risk of ceasing to try to work and fit into their communities.

Cont(2)

We have suggested that when stigma leads to an impoverished sense of self, low self-esteem and suicide risk follow. This model can not only be tested empirically but it may expose a chain of thoughts and behaviors that could be individually targeted for intervention.

CRITICAL APPRAISAL

Journal identity
The study come from : Psychology Department, John Jay College of Criminal Justice, City University of New York, New York, USA Authors: Philip T. Yanos David Roe Paul H. Lysaker

Cont(2)
Published by:

American Journal of Psychiatric Rehabilitation, 13: 73 93, 2010 Copyright # Taylor & Francis Group, LLC ISSN: 1548-7768 print=1548-7776 online DOI: 10.1080/15487761003756860
Available at: http://dx.doi.org/10.1080/15487761003756860

Cont(3)
Titles:

The Impact of Illness Identity on Recovery from Severe Mental Illness

Positive: Clearly shows that variables that were investigated Bold written There is no abbreviation Less than 12 words (11 words)

Negative: No location No time

Abstract
Consist only 3 sections Aim Keywords Conclusion < 250 words (113 words)

The Model
Positive:
The diagram of the model is clear. The examples is clear and easy to be understood.

Negative:
The outcomes are not clear The explanation is not clear and always being explained superficially

Review of Evidence for the Model

Positive There is explanation for every reviews The authors compared every hypothesis with the other journals or articles with reliable refrences. The usage of examples from authors is suitable with the context of reviews - Negative : The explanation has been discussed briefly. There is no further explanation for the context of reviews.

Discussion
Positive The authors matched the solutions according to the previous research. The examples is suitable with the context and easily be understood by the readers. - Negative : The authors discussed only for few suggestions or solutions. The authors held on too much assumptions.

Conclusion
The authors tried to discuss an interesting title,but not successfully to elaborate the contents same with the readers expectations. They came up with easy examples but there is no further explanation for the content that been discussed. There is no new findings in their journal as they chose to compare their hypothesis with the previous journals. Overall,the journal is good to get the additional informations about illness identity.