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| Identity in the Moratorium Stage: Loss of Sense of Self |
Identity in the Moratorium Stage: Loss of Sense of Self
The loss of sense of self and one’s identity is one of the most devastating consequences of serious mental illness. In the Moratorium stage, the person feels as though they no longer know who they are as a person. For example:
My illness eradicated my sense of self, and now I am engaged in the lifelong process of obtaining, maintaining and slowly modifying my sense of who I am. (Anonymous, 1994b, p. 25)
The loss of sense of self and one’s identity is one of the most devastating consequences of serious mental illness. In the Moratorium stage, the person feels as though they no longer know who they are as a person. For example:
My illness eradicated my sense of self, and now I am engaged in the lifelong process of obtaining, maintaining and slowly modifying my sense of who I am. (Anonymous, 1994b, p. 25)
Two schools of thought exist as to the role of loss of self in schizophrenia (Estroff, 1989). The first, a clinical view, is that the illness constitutes the loss or absence of a sense of self. This concept has been examined from the perspectives of psychoanalytic self-psychology (e.g. Kohut and Wolf, 1978; Pollack, 1989), personal construct psychology (e.g. Gara, Rosenberg and Mueller, 1989; Rosenberg, 1993) and neuropsychology (e.g. Hemsley, 1998; Vogeley et al., 1999). In a case study investigating the loss of volition, Lysaker and Bell (1995) proposed that a fundamental disturbance of identity was the basis of the person’s inability to pursue a direction in life: activity derives its meaning from the individual’s sense of identity. Deprived of a sense of one’s self, there is no basis for purposeful choice of activity. The second, social psychological view of loss of identity, is that the illness results in a loss of, or change in, the sense of self (e.g. Goffman, 1968; Erikson, 1975; Charmaz, 1983). This explanation was elaborated in relation to physical illness (Charmaz, 1983), and was applied by Pettie and Triolo (1999) to explain loss of identity in serious mental illness. Another theory of the loss of self in schizophrenia is the phenomenological view (Davidson, 1994). Davidson described a fundamental loss of a sense of self as stemming from symptoms such as hallucinations and thought insertion, which cause the person to feel that he or she can no longer trust his or her own perceptions, and can lead to a feeling of external control (Davidson, 1994). While not denying the possibility of the aetiological explanation of the relationship between the self and schizophrenia, or ignoring the phenomenology of a loss of sense of self, the consumer literature clearly focuses on the psychosocial effects of mental illness on the sense of self and identity.
Erikson (1968) described a person’s identity as a ‘progressive continuity between that which he has come to be during the long years of childhood, and that which he promises to become in the anticipated future’ (p. 87). When a person loses the sense of continuity of the self, they suffer a crisis of identity (Erikson, 1968). Erikson described how some Second World War veterans seemed to lose their sense of identity: ‘They knew who they were; they had a personal identity. But it was as if, subjectively, their lives no longer hung together—and never would again’ (Erikson, 1963, p. 42). Kelly and Millward (2004) differentiate between two forms of identity:
the self – referring to private identity; and identity which refers to social identity – or identity as it relates to others. With the onset of a severe and enduring mental illness, a number of processes come into play to undermine the sense of continuity of the self and of the social identity. First, the symptoms of the illness can include memory impairments that disrupt the person’s sense of self through the loss of a sense of continuity between past, present and future identity (Davidson, 2002). Then, as described by Charmaz (1983), chronic illness – whether physical or mental – may rob the person of his or her close relationships, educational and/or occupational aspirations, social life and autonomy, thus undermining his or her social identity.
Leibrich (1997) explains:
I tried to pick up what was left of my life. But in the course of my illness and treatment I had lost my studies, my marriage, my home, and most of my friends. I returned to a community where I didn’t belong any more . . .. (p. 39)
Erikson (1968) described a person’s identity as a ‘progressive continuity between that which he has come to be during the long years of childhood, and that which he promises to become in the anticipated future’ (p. 87). When a person loses the sense of continuity of the self, they suffer a crisis of identity (Erikson, 1968). Erikson described how some Second World War veterans seemed to lose their sense of identity: ‘They knew who they were; they had a personal identity. But it was as if, subjectively, their lives no longer hung together—and never would again’ (Erikson, 1963, p. 42). Kelly and Millward (2004) differentiate between two forms of identity:
the self – referring to private identity; and identity which refers to social identity – or identity as it relates to others. With the onset of a severe and enduring mental illness, a number of processes come into play to undermine the sense of continuity of the self and of the social identity. First, the symptoms of the illness can include memory impairments that disrupt the person’s sense of self through the loss of a sense of continuity between past, present and future identity (Davidson, 2002). Then, as described by Charmaz (1983), chronic illness – whether physical or mental – may rob the person of his or her close relationships, educational and/or occupational aspirations, social life and autonomy, thus undermining his or her social identity.
Leibrich (1997) explains:
I tried to pick up what was left of my life. But in the course of my illness and treatment I had lost my studies, my marriage, my home, and most of my friends. I returned to a community where I didn’t belong any more . . .. (p. 39)
When a person’s goals for the future are lost through uncontrollable events, their hoped-for possible self is also lost (King, 1998). Therefore, a person with a mental illness may find it impossible to imagine a positive ‘future self’ (Pettie and Triolo, 1999). Deegan (1997), at 17 years of age, had yet to start on her adult life course when her dreams were negated: ‘My teenage world in which I aspired to dreams of being a valued person in valued roles . . . I felt these parts of my identity being stripped from me’ (p. 16).
And for an established professional, the effects are no less devastating, as made clear by Wentworth (1994), who had practiced many years as a psychotherapist before developing bipolar disorder. She writes:
At the age of forty-three . . . I was hurled into a new arena . . . far into the side of life I had tried to help my clients avoid, the brutal, the ugly, the shadow side. I found myself in the space of the marginal, the deviant, the disabled . . .. I had landed myself in Hell.
There I felt stark terror, the pain of rejection by people I trusted the most, isolation, deprivation, and unworthiness. The loss of power and respect was like being in a black hole where I had to fight my way out using all the skills and strengths I could summon. (p. 80)
Diagnosis and treatment, with the concomitant conferring of the ‘mentally ill’ label, robs the person of his or her sense of identity as a valuable and functioning member of society (e.g. Murphy, 1998; Henderson, 2004). According to Estroff (1989), schizophrenia can cause a more profound sense of loss of self than other chronic illnesses, as it may entail ‘becoming a schizophrenic’. Bjorklund (1998) told in Chapter 1 how he left hospital, after only three weeks, as ‘a schizophrenic’. Thus, the illness becomes part of the known self and of the social identity. The pre-illness self is usually perceived as ‘successful, reliable, healthy, well and better . . .. The present self . . . is perceived as unreliable, unsuccessful, sick, weird and worse’ (Pettie and Triolo, 1999, p. 256). For example:
The locked doors of the psych ward separating us from ‘normal’ people became my dominant metaphor. I was a resident of the psych ward wherever I went geographically. Me as ‘crazy’ now replaced every other image I had formed about myself – scholar, musician, poet. (Fekete, 2004, p. 190)
Labelling a person’s problems as schizophrenia has a negative affect on the response of others towards that person, and engenders social distancing (Angermeyer and Matschinger, 2003). This stigma contributes to the poor outcomes of people with mental illness (Arboleda-Florez, 2003; Couture and Penn, 2003). Here Murphy (1998) describes stigma as the source of helplessness:
No, the psychotic symptoms were not the cause of my despair. It was realizing that, because there is no cure for schizophrenia, I must wear this label for the rest of my life, and as a result of it, be considered different and treated as an inferior being. (p. 186)
And for an established professional, the effects are no less devastating, as made clear by Wentworth (1994), who had practiced many years as a psychotherapist before developing bipolar disorder. She writes:
At the age of forty-three . . . I was hurled into a new arena . . . far into the side of life I had tried to help my clients avoid, the brutal, the ugly, the shadow side. I found myself in the space of the marginal, the deviant, the disabled . . .. I had landed myself in Hell.
There I felt stark terror, the pain of rejection by people I trusted the most, isolation, deprivation, and unworthiness. The loss of power and respect was like being in a black hole where I had to fight my way out using all the skills and strengths I could summon. (p. 80)
Diagnosis and treatment, with the concomitant conferring of the ‘mentally ill’ label, robs the person of his or her sense of identity as a valuable and functioning member of society (e.g. Murphy, 1998; Henderson, 2004). According to Estroff (1989), schizophrenia can cause a more profound sense of loss of self than other chronic illnesses, as it may entail ‘becoming a schizophrenic’. Bjorklund (1998) told in Chapter 1 how he left hospital, after only three weeks, as ‘a schizophrenic’. Thus, the illness becomes part of the known self and of the social identity. The pre-illness self is usually perceived as ‘successful, reliable, healthy, well and better . . .. The present self . . . is perceived as unreliable, unsuccessful, sick, weird and worse’ (Pettie and Triolo, 1999, p. 256). For example:
The locked doors of the psych ward separating us from ‘normal’ people became my dominant metaphor. I was a resident of the psych ward wherever I went geographically. Me as ‘crazy’ now replaced every other image I had formed about myself – scholar, musician, poet. (Fekete, 2004, p. 190)
Labelling a person’s problems as schizophrenia has a negative affect on the response of others towards that person, and engenders social distancing (Angermeyer and Matschinger, 2003). This stigma contributes to the poor outcomes of people with mental illness (Arboleda-Florez, 2003; Couture and Penn, 2003). Here Murphy (1998) describes stigma as the source of helplessness:
No, the psychotic symptoms were not the cause of my despair. It was realizing that, because there is no cure for schizophrenia, I must wear this label for the rest of my life, and as a result of it, be considered different and treated as an inferior being. (p. 186)
Loss of a positive identity can also be engendered by self-stigma: previously internalized negative conceptualizations of people with a mental illness applied to the self (Lally, 1989; Corrigan and Watson, 2002). For example: ‘But accepting the diagnosis was, for me, most difficult because I had to overcome my own stigma about being one of them’ (Henderson, 2004, p. 85), and ‘In my own mind I thought I was less than a part of the human race. I was on the other side of the wall between “normal” people and “crazy” people. I had left society and become a “mental patient.”’ (Fekete, 2004, p. 190)
These negative attitudes are then projected onto others. The person expects rejection in social situations, and so avoids them – even if the expectation of rejection is not justified by any actual experience of stigma (Lally, 1989). For instance: ‘In fact, I carried the stigma myself! And had I not isolated myself by my own self-image, I felt assured that other people would isolate me if they found out I was a mental patient.’ (Fekete, 2004, p.190)
This self-protective avoidance illustrates another contribution to the withdrawal seen in the Moratorium stage. An anonymous author provides this interesting insight on passivity in the face of an unacceptable identity:
As someone who had not only produced and functioned professionally, but felt I was worthless if I didn’t do so, it was quite a comedown when the medication stopped working. Thus my tendency in the past was to sit out life until I could be my ideal self, unwilling to acknowledge my imperfections and limitations or discuss them with my therapist. (Anonymous, 1994a, p. 15)
Stigma can be exacerbated by the attitude of clinicians and staff in treatment facilities (Frese, 2000; Sartorius, 2002). Deegan (1990) described the abuse of people in institutions as an underlying cause of despair. But overt physical or psychological abuse is not necessary for the transmission of stigmatizing attitudes. Chaplin (2000) found that psychiatrists often hold the same prejudices about people with mental illness as the wider population. Leibrich (1997) described earlier how the communication barrier between staff and patients led her to become ‘almost catatonic’ (p. 38). She continues: ‘So people tried to pull me out of my darkness. Some tried to coax me out, others shame me out, drug me out, and get me into their light. Get me out of . . . my . . . self’ (p. 38; ellipses in original). Fekete (2004) describes a more subtle effect of the power imbalance between the practitioner and the client: ‘Her clinical posture deprived me of a feeling of full personhood and reinforced the doctrine that I was her “mental patient”’ (p. 191).
The perceived inability to reaffirm an identity or sense of belonging can lead to defensive internalization of the illness identity (Rooke and Birchwood, 1998).
Acceptance of the ‘mentally ill’ label can lead to engulfment in the patient role (Estroff, 1989; Lally, 1989; Gray, 2002). This entrapment in the patient role stems from the perception that relationships, core roles and autonomy are no longer available (Rooke and Birchwood, 1998). With this loss of a sense of self, and the emergence of the patient role, the person’s expectations of him or herself are lowered (Hayward and Bright, 1997), contributing to the loss of motivation seen in this stage.
Given the consequences of the stigma engendered by the label, a person, while accepting that his or her experiences are not normal, may reject the diagnostic label (e.g. Lally, 1989; Schmook, 1994; Pettie and Triolo, 1999; Bassman, 2000). Often construed as denial, this can be a self-protective reaction to the new identity that is inherent in the diagnosis: ‘Our denial was an important stage in our recovery. It was a normal reaction to an overwhelming situation. It was our way of surviving those first awful months’ (Deegan, 1988, p. 55).
When the self is under threat, strategies of reality negotiation are employed to protect the self-image (Snyder, 1989). The person distances him- or herself from information that has negative implications for the self, while maintaining beliefs that enhance the self (Snyder, 1989). The above quotes from consumers bring into question the wisdom that acceptance of the illness is an important precursor to coping with illness. Instead, acceptance can be a barrier to the active recovery process by encouraging resignation and passivity (Lally, 1989).
Deegan (1997) asserted that acceptance of the patient role resulted in there being ‘no-one left inside’ to do the work of recovery. A person’s sense of self and identity provides a basis for the meaning in one’s goals in life (Lysaker and Bell, 1995), and in the following section we will explore the loss of meaning and purpose in life in serious mental illness.
This self-protective avoidance illustrates another contribution to the withdrawal seen in the Moratorium stage. An anonymous author provides this interesting insight on passivity in the face of an unacceptable identity:
As someone who had not only produced and functioned professionally, but felt I was worthless if I didn’t do so, it was quite a comedown when the medication stopped working. Thus my tendency in the past was to sit out life until I could be my ideal self, unwilling to acknowledge my imperfections and limitations or discuss them with my therapist. (Anonymous, 1994a, p. 15)
Stigma can be exacerbated by the attitude of clinicians and staff in treatment facilities (Frese, 2000; Sartorius, 2002). Deegan (1990) described the abuse of people in institutions as an underlying cause of despair. But overt physical or psychological abuse is not necessary for the transmission of stigmatizing attitudes. Chaplin (2000) found that psychiatrists often hold the same prejudices about people with mental illness as the wider population. Leibrich (1997) described earlier how the communication barrier between staff and patients led her to become ‘almost catatonic’ (p. 38). She continues: ‘So people tried to pull me out of my darkness. Some tried to coax me out, others shame me out, drug me out, and get me into their light. Get me out of . . . my . . . self’ (p. 38; ellipses in original). Fekete (2004) describes a more subtle effect of the power imbalance between the practitioner and the client: ‘Her clinical posture deprived me of a feeling of full personhood and reinforced the doctrine that I was her “mental patient”’ (p. 191).
The perceived inability to reaffirm an identity or sense of belonging can lead to defensive internalization of the illness identity (Rooke and Birchwood, 1998).
Acceptance of the ‘mentally ill’ label can lead to engulfment in the patient role (Estroff, 1989; Lally, 1989; Gray, 2002). This entrapment in the patient role stems from the perception that relationships, core roles and autonomy are no longer available (Rooke and Birchwood, 1998). With this loss of a sense of self, and the emergence of the patient role, the person’s expectations of him or herself are lowered (Hayward and Bright, 1997), contributing to the loss of motivation seen in this stage.
Given the consequences of the stigma engendered by the label, a person, while accepting that his or her experiences are not normal, may reject the diagnostic label (e.g. Lally, 1989; Schmook, 1994; Pettie and Triolo, 1999; Bassman, 2000). Often construed as denial, this can be a self-protective reaction to the new identity that is inherent in the diagnosis: ‘Our denial was an important stage in our recovery. It was a normal reaction to an overwhelming situation. It was our way of surviving those first awful months’ (Deegan, 1988, p. 55).
When the self is under threat, strategies of reality negotiation are employed to protect the self-image (Snyder, 1989). The person distances him- or herself from information that has negative implications for the self, while maintaining beliefs that enhance the self (Snyder, 1989). The above quotes from consumers bring into question the wisdom that acceptance of the illness is an important precursor to coping with illness. Instead, acceptance can be a barrier to the active recovery process by encouraging resignation and passivity (Lally, 1989).
Deegan (1997) asserted that acceptance of the patient role resulted in there being ‘no-one left inside’ to do the work of recovery. A person’s sense of self and identity provides a basis for the meaning in one’s goals in life (Lysaker and Bell, 1995), and in the following section we will explore the loss of meaning and purpose in life in serious mental illness.
