Autobiography as Tool to Improve Lifestyle, Well

ORIGINAL ARTICLE

Autobiography as Tool to Improve Lifestyle, Well Being, and Self-Narrative in Patients With Mental Disorders Andrea Smorti, PhD, Bianca Pananti, and Aida Rizzo

Abstract: The aims of the present study were to explore how the autobiographical process can lead to a transformation in psychiatric patients’ lifestyle, well-being, and self-narrative. Nine participants, aged between 20 and 42 years and affected by axis I psychiatric disorders (DSM IV) were selected to participate in an autobiographical laboratory. Eight to 10 meetings took place, each lasting about an hour, during which autobiographical accounts were collected. At the beginning and end of the autobiographical laboratory, the medical staff completed the Social Functioning Scale to evaluate each patient across 6 dimensions: social engagement, interpersonal ability, prosocial activities, recreation, independence-competence, and independence-performance. The Language Inquiry and Word Count (Pennebaker and Francis, 1996) was used to analyze patients’ autobiographical accounts. A comparison between the first and second compilation of the Social Functioning Scale showed significant positive changes across the 6 social dimensions. The analysis of language in the narratives collected in the first and seventh meeting showed how inpatients passed from a narrative that was more centered on the memory of the past to a narrative that was more similar to a conversation and enriched with “insight” terms and the use of verbs in the conjunctive form. The authors interpret these outcomes as being consistent with the improvement that was observed in inpatients’ social functioning. Key Words: History of life, psychiatric inpatient, psychotherapy, autobiographical laboratory. (J Nerv Ment Dis 2010;198: 564 –571)

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he present study explored the effects of the autobiographical process on psychiatric inpatients’ well being and social functioning. Psychiatric patients have been evaluated as being incapable of narrative ability because of an impaired capacity to have both internal and external dialogue, with the self and the therapist, respectively (Lysaker and Lysaker, 2002; Hambleton et al., 1996). Perhaps, because of the recent socioconstructivistic and postmodern turn (Bruner, 1986; Hermans, 1996a; Sarbin, 1989), clinical researchers have proposed that autobiographical narratives can serve to shed light on the world of psychosis. Lysaker and coworkers, (Lysaker and Lysaker, 2001; Lysaker and Lysaker, 2002; Lysaker and Daroyanni, 2006a) for instance, argued that patients with schizophrenia are not entirely incapable of dialogue—as long as therapists show an appropriate attitude toward them, using a respectful attitude of curiosity toward the patient’s world and creating an intersubjective space as a foundation for the development of empathy. Furthermore, although disruptions of personal narratives can be particularly profound and pronounced during

Department of Psychology, University of Florence, Firenze, Italy. Preparation of this article was primarily supported by the Florence Health Company (2007 grant). Send reprint requests to Andrea Smorti, PhD, Department of Psychology, Via di San Salvi, 12, Complesso di San Salvi Padiglione 26, 50135 Firenze, Italy. E-mail: [email protected]. Copyright © 2010 by Lippincott Williams & Wilkins ISSN: 0022-3018/10/19808-0564 DOI: 10.1097/NMD.0b013e3181ea4e59

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psychosis, the process of “meaning making” remains present in many or most individuals (Hermans, 1996a, b; Hermans and Di Maggio, 2004; Lysaker et al., 2003a). These authors perceive that mental illness does not destroy the content, but rather the structure and coherence of speech. Acute psychosis is accompanied by a desire to narrate current or past experiences related to one’s symptoms. Yet, the inability to order these experiences in time and to narrate them disrupts ill individuals’ sense of identity, impairs their sense of agency, and leaves them trapped in an unstructured, chaotic present (France and Uhlin, 2006). According to these authors, autobiographical narration can be a useful tool for the renewal of the dialogue process in patients with psychosis, creating new conversational paths and retrieving apparently inaccessible material. Thus, narrative of psychosis shows promise for offering unique opportunities to examine the various aspects of disordered narratives and to explore how these narratives can change as people move toward recovery (France and Uhlin, 2006). As Hambleton et al. (1996) have emphasized, autobiographical experience can be highly therapeutic because it reveals the fragmented, split self to patients and allows them to gain awareness of their “1, none, 100,000.” There are other reasons, however, that encourage the use of a narrative approach with psychiatric patients. One of these concerns is the substantial changes that autobiographical memory undergoes when it is transformed into autobiographical narrative. During this process, narrators do not simply recount what has happened to them, but they also provide themselves and their listeners with an interpretation of the event, by attributing new meaning to it. This process can be easily observed in the function of autobiographical memory in managing information related to the self (Brewer, 1996). To do so, it relies on meaning structures called “schemas” (Bartlett, 1932) or self themes (Conway, 1996, 2005), which operate as active “rebuilders” of experience. These structures not only guide the retrieval of events, but also set these events in a semantic plot line and endow them with narrative organization. Moreover, by telling a story we influence our autobiographical memory to reconstruct memories on the basis of the particular self themes or narrative schemas that prevail at the moment of remembering. That is, at the moment of a dialogue between the narrator and listener. In other words, the act of narrating makes memories contingent on social communication between at least 2 people, in the present. There is evidence that producing autobiographical narratives can help the narrator to heal or, at least, to improve his or her personal well being. In the psychoanalytic field Schafer (1992), Spence (1982), and White (1990) have demonstrated that the “self renarration” processes that occur in psychoanalytic sessions have a therapeutic value because these stimulate insight, the reformulation of one’s life history, and the attribution of a new structure to life events. From a more cognitive stance, Pennebaker (Pennebaker 1997; Pennebaker and Seagal, 1999) used the “expressive writing” technique to improve physical and psychological well being in college students. In the psychiatric field Lysaker and coworkers have observed significant changes in patients’ narratives and psychological well being during the psychotherapeutic process (Lysaker et al., 2003a; Lysaker et al., 2003b; Lysaker et al., 2003c; Lysaker and

The Journal of Nervous and Mental Disease • Volume 198, Number 8, August 2010


Lysaker, 2004). Lysaker used the dialogical self as a theoretical framework and detected changes in psychotic patients’ narratives using the Scale to Assess Narrative Development. Changes were observed not so much in content as in the form of narratives. Over time, the patients’ narratives began to show significant increases in the frequency of interaction with other characters, the number and complexity of self-positions, and in the proportion of positive versus negative self-positions. Lysaker et al. therefore concluded that narrative transformations in psychosis can be viewed in terms of dialogical improvement and a greater degree of narrative complexity, dynamism, and subtlety. Recently, Smorti et al. (2008) attempted to explore how the autobiographical process could lead to a transformation in the quality of psychiatric patients’ well being and self-narrative. Fifteen inpatients in a residential center, aged between 25 and 40 years, who were affected by axis I psychiatric disorders (DSM IV) were selected to participate. The intervention was integrated with the Center’s daily activity schedule. Participants were interviewed twice. After the first autobiographical interview, verbal protocols were transcribed from the audio-recorded interviews. The second interview took place 15 days later, and during it the interviewer started showing the patients the text from the first narrative in order. They were able to read it and, if they wished, modify the text or simply continue narrating. Qualitative and quantitative methods were used to analyze the texts. The results showed statistically significant differences in the type of elements that were produced in the 2 interviews, with the second interviews being richer in indicators of the active self, self as narrator, self-evaluations, and causal connectives than the first interviews had been. The position of the narrator was more evident, both in terms of expression of self as narrator and of the general analysis of emotions and memories. The findings gleaned from the text analysis were confirmed by the participants’ reactions to the research experience. They all reported experiencing feelings of well being at the second interview and, more importantly, after the second narration they expressed a sense of greater clarity and personal gratification, because of the interest shown in their personal histories. The medical staff conducted a clinical assessment of patients after the second interview and concurred that there had been an improvement in their well being. Overall there is evidence that psychiatric patients can exploit the resources provided by autobiographical or narrative techniques, that these techniques can help them to organize their autobiographical memories, and that narrative interview represents a useful tool for getting in touch and communicating with these patients. Improvements were also observed in their health (Lysaker et al., 2003a). The literature cited illustrates how psychiatric patients are able to reconstruct memories and give them a new form when given an opportunity to narrate their personal life stories in an appropriate context. An assumption of the literature cited in the introduction was that an improvement in the capacity to narrate one’s own experience might also produce an improvement in patients’ well being. The present study was conducted within this theoretical framework. The main novel aspect of the current study is the type of autobiographical method used. It consists of an autobiographical interview that is repeated several times, which provides the patients with the opportunity to produce different versions of their autobiographical narratives and to correct these versions by means of a written text. As will be explained, the interviewed patients are the authors of their “my life history book” and the interviewer is their editor. In this way, narrating one’s own life story is really a building and cooperative process that can be continuously modified. The aim of the present study is 2-fold: to assess whether creating an autobiographical laboratory with psychiatric patients © 2010 Lippincott Williams & Wilkins

Autobiography as a Tool

improves their psychosocial adaptation, and to asses whether these patients change their way of narrating their life, rendering their narratives more contingent to the present interchange with the interviewer.

METHOD Participants Our participants were 9 inpatients (4 men and 5 women— henceforth called “narrators”), aged 20 to 42 years, all of whom met Axis I disorder criteria as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV, American Psychiatric Association, 1994). All narrators were clients of a psychiatric residential center located in the metropolitan area of the City of Florence, Italy. They had previously been diagnosed with chronic psychiatric disorders and had been referred to the Residential Center for Psychiatric Disorders, after repeated hospitalization in the Florence General Hospital’s psychiatric department. Given their impaired personal and social skills, they experienced serious difficulties in the areas of parenting, maintaining a sentimental relationship, and performing a job or academic activities. Therefore, narrators required a sheltered environment that ensured both appropriate pharmacological treatment and access to a therapeutic-rehabilitative program focused on the achievement of personal autonomy. At the time of the interview, the participants were classified as experiencing schizophrenia (4 patients), schizoaffective disorder (2 patients), cyclothymic disorder (2 patients), and major depression (1 patient). Narrators were selected by the Center’s staff following careful scrutiny and according to the likely prospect of their potential positive reaction to the autobiographical laboratory. None of them refused to participate.

Procedure The study was presented as a proposed intervention based on autobiography to the residential center staff, at a meeting attended by the physicians in charge and representatives of the Mental Health Service. We explained that our aim was to implement an autobiographical laboratory in the center’s care system and to assess its effects on the patients. We assumed that the autobiographical process in the laboratory would improve patients’ psychosocial adaptation. The center staff chose to include the proposed autobiographical activity in their therapeutic-rehabilitative program by integrating it into the center’s daily activity schedule. Following staff approval, the entire autobiographical laboratory program was presented at a group meeting attended by patients and therapists, as an occasion for the patients to dedicate sometime to themselves and as an activity that could help them in reconstructing their life stories. All 9 patients consented to participating in the intervention. The autobiographical laboratory used 2 main instruments that were the interview and the protocol.

The Interview Narrators gave their autobiographical accounts in more than 8 to 10 meetings, each of which lasted about an hour on an average. The interviewer was a psychologist and expert in narrative-autobiographical techniques who worked under the clinical supervision of the center’s staff. The first interview was preceded by a “warming up” phase: the interviewer became acquainted with the narrators over the course of several days, so as to not be perceived as an “outsider.” The narrators’ permission to record the interview was requested, and they were assured that their autobiographical productions would be confidentially treated. Only consenting narrators participated in the intervention. The interviews with the narrators were conducted in accordance with the McAdams’ Model (1996), and the main guidelines www.jonmd.com | 565

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for administering an autobiographical-narrative interview, as described in Alheit and Bergamini (1996), and adapted to the selected sample’s requirements. First, the interviewer strove to respect the narrators’ wishes by answering any questions and by reassuring them about any feelings of uncertainty or resistance they had concerning the idea of self-narration that they might have been experiencing. Second, the duration of the narration was decided by the narrator. The interviewer therefore respected all silences, however lengthy, throughout the narrations. Finally, although the interviewer was sincerely interested in each participant’s narrative, she refrained from intruding with any attempts of interpretation. The narrators were therefore left completely free to follow the flow of their own thoughts and to present any facts they considered pertinent to the meaning they desired to attribute to their narrations. A completely unstructured approach with psychiatric patients, however, would have run the risk of the dispersal of ideas or stories, or the presentation of a predefined script. The interviewer therefore chose to introduce some “constraints,” which partially structured the interviews, but nevertheless respected the freedom of expression that is inherent in autobiography. The interview was loosely constructed around 10 codified cruxes that explored the important topics of self (family, entertainment, friendships, significant relationships, school years, jobs, love, interests, passions, expressive-artistic activities). These guidelines allowed us to structure the participants’ autobiographical accounts around particularly salient themes, but also allowed the narrators to produce spontaneous and free flowing narrations. The formulation of the questions was kept as flexible as possible to adapt the interview to each patient’s spontaneous narrations. The narrators were also given the opportunity to use other tools for their narration. These were photo language, narrative collage, narrative stimuli such as music, songs, musical instruments, photographs, drawings, paintings, significant objects, and any other type of expressive activity and tool narrators liked, which could be useful to evoke their autobiographical memories.

The Protocol Each narrator’s verbal productions during the interviews were audio-recorded, transcribed, and then revised with the narrator. In the first and second meeting a first version of the narrator’s life history was collected. The tape was then transcribed by the interviewer and presented to the patient at the third meeting. The narrator and interviewer had the opportunity to read the whole text or part of it, as the narrator wished, and the interviewer was then able to correct, integrate, and modify it by adding further parts of the narrator’s life story. Afterward, without the presence of the narrator, the interviewer transcribed the narrator’s words and integrated these into the previous text. In this way a second text was constructed. By the fourth and fifth meetings the autobiographical interview usually carried on. The interviewer might have wanted to gather more information about some parts of the text or address further questions that had not yet been posed to the narrator. Again the tape was transcribed and presented to the narrator during the sixth meeting for further modifications, which were completely integrated into the existing text and presented to the narrator. In the seventh meeting the narrator was again requested to go on telling his or her life story. The protocol may have differed from one narrator to another depending on the relationship between the narrator and interviewer and the flow of the interview, but the eighth meeting and the ensuing transcription was usually devoted to composing the complete text of the narrator’s life history and inserting verbal memories and images (photos, pictures) that he or she proposed as being an important integration to their life history. The aim was to eventually edit “the book of my life” as a product belonging to the narrator, something private which he or she could, if desired, show to others. In accordance with the main principles of 566 | www.jonmd.com

the autobiographical approach, the participants were asked to give their story a title once they had finished telling it. They also could assign a title to each singular “chapter” if they liked. Finally, all narrators received both the complete texts of their self-narrations (with the chosen title printed on the cover page) and copies of the recorded tapes (see Figs. 1 and 2 for an example of “The book of my life story” and for the protocol scheme). All the patients reacted positively to the activity and it was generally received with enthusiasm. Behind the rationale of the protocol is the assumption that a narrative process can have positive effects on the narrators if they are provided with a tool to reflect on their memories. This tool was represented, in our protocol, by the materialization of their memories through the text. Reading the text, as an outcome of their memories, and being able to correct it, not only gave the narrators the possibility to become conscious of their narrative, but helped them to consider their life story as something that could be modified. To measure any changes that occurred in the narrators’ psychosocial adaptation, at least 2 members from the medical and paramedical staff administered the Social Functioning Scale (SFS) (Birchwood et al., 1990) at the beginning and end of the autobiographical laboratory. This is a 79-item scale designed to assess the social functioning of individuals with a diagnosis of schizophrenia. The scale evaluates a person’s abilities and performance in the following 6 areas: a. Social engagement (time spent alone, initiation of conversations); b. Interpersonal ability (number of friends/heterosexual contact, quality of communication); c. Prosocial activities (engagement in a range of common social activities, e.g. sport); d. Recreation (engagement in a range of hobbies, interests, pastimes, etc.); e. Independence-competence (ability to perform skills necessary for independent living, e.g., to cook for oneself, personal hygiene, household cleanliness, money management). The scale measures the degree to which one is able to take on several tasks (incapable, or only with substantial help; with help; or sufficiently). f. Independence-performance (performance of skills necessary for independent living, e.g., to catch a train). The frequency with which the narrator takes on several tasks is measured (never, rarely, sometimes, often).

FIGURE 1. The book of my life story. © 2010 Lippincott Williams & Wilkins



Moreover, the scale investigated whether the participant had attempted to find a job or whether he or she had obtained a job. The scale was validated on a Castillano sample (Torres and Olivares, 2005). Its authors have shown its reliability, validity, and sensitivity across schizophrenic and control samples. The questionnaire can be filled out by the respondent, but in our study the medical staff completed the form by both observing the narrators and asking them the questions. Differences between the first and second SFS evaluations were considered to represent an index of change. Narratives were analyzed using LIWC (Language Inquiry and Word Count, Pennebaker and Francis, 1996) software. This permits the quantification of the total number of words in a narration and the rate of words belonging to each of the categories, amended for our purposes in the dictionary as semantic categories, such as “cognitive words” or “emotion words,” grammatical words like in articles or adverbs or syntactic ones like “personal prepositions,” “causal or temporal connections,” etc. The LIWC software contains a dictionary that permits recognition of the words in the text. In our case study, we used an Italian version of this dictionary, which was originally devised by Pennebaker’s team and then elaborated by us to adapt it to our research. We used the LIWC to analyze narrations in relation to personal pronouns, verbs, and mental states. Verbs included time orientation (past, present, and future) and form (indicative and conjunctive). Mental states included anxiety, sadness, and introspective mental states. To give a deeper interpretation to quantitative outcomes regarding word categories, we also checked the contexts to which they belonged using T-Laboratory (T-Laboratory 7.0, Lancia, 2001–2007).

RESULTS Table 1 shows the medical staffs’ evaluations (according to the SFS subscales) of the 9 narrators’ behavior before and after their participation in the autobiographical laboratory. Overall the comparison shows how narrators improved in all the areas of social functioning tested by the subscales. To test for any differences between the 2 evaluations we used a Wilcoxon-Mann-Whitney U test. This test may be used in small (N ⬍10) samples (Siegel and Castellan, 1988). Results are presented

FIGURE 2. The autobiographical protocol.

TABLE 1. Medical Staff’s Evaluations (SFS Scales) of the 9 Narrators’ Behaviors Before and After Their Participation in the Autobiographical Laboratory Social Engagement Name AP LB LM EL MS SCAR SCA SF LABE Mean SD W/M W test

Gender M M F F M M F F F

Test

Retest

9.00 13.00 8.00 15.00 5.00 14.00 11.00 12.00 8.00 13.00 7.00 14.00 5.00 13.00 8.00 12.00 13.00 12.00 8.2 13.1 2.58 1.05 ⫺2.49**

Interpersonal Ability Test

Retest

13.00 17.00 14.00 17.00 10.00 19.00 14.00 20.00 13.00 19.00 9.00 19.00 16.00 19.00 11.00 15.00 14.00 22.00 12.6 19 2.23 1.6 ⫺2.52**

Prosocial Activity Test

Retest

15.00 21.00 14.00 17.00 12.00 34.00 19.00 35.00 23.00 32.00 14.00 33.00 12.00 38.00 13.00 28.00 11.00 26.00 14.77 29.33 3.86 6.92 ⫺2.66**

Recreation Test

Retest

13.00 16.00 6.00 12.00 10.00 16.00 14.00 12.00 14.00 15.00 5.00 16.00 9.00 21.00 8.00 20.00 24.00 23.00 11.44 16.77 5.74 3.8 ⫺2.13*

IndependencePerformance

Independence/ Competence

Test

Test

Retest

30.00 33.00 27.00 27.00 24.00 37.00 32.00 36.00 28.00 38.00 16.00 25.00 29.00 36.00 33.00 36.00 36.00 37.00 28.33 33.88 5.8 4.7 ⫺2.52**

Retest

17.00 17.00 9.00 16.00 17.00 27.00 15.00 24.00 6.00 17.00 7.00 16.00 16.00 24.00 24.00 29.00 30.00 30.00 15.66 22.2 7.84 5.78 ⫺2.37*

*p ⬍ 0.05. **p ⬍ 0.01.

© 2010 Lippincott Williams & Wilkins

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in the last row of Table 1. The test-retest difference for each subscale was significant (0.05– 0.01). In comparison with the first evaluations, the 9 narrators were described in the second ones as getting up earlier in the morning, spending less time alone, and going out of the home more frequently. They initiated conversation more often when they were at home and were less avoidant in the presence of others (social engagement). They liked being in groups with friends or relatives more, discussing current events or personal problems, and were more able to maintain a meaningful conversation (interpersonal ability). They devoted more time to activities such as going to the cinema, doing sport, visiting relatives or friends, and attending parties (prosocial activity). They developed a hobby like gardening, sewing, reading, listening to music, table games, or handcrafts (recreation). Narrators were evaluated to be more autonomous, to demonstrate greater self-care, to be more able to manage their current duties, to use money appropriately, to go by themselves to stores or agencies, and to use means of transport (independenceperformance; independence-competence). They were also more involved in finding a job and 4 of them got one. As for the text analysis of the autobiographical accounts, Table 2 shows the means and standard deviations of the number of words, the percentage of words captured, personal pronouns, mental states, and the tense and form of the verbs measured using LIWC. The number of words and percentage of words captured by the dictionary did not vary significantly from the first to the fifth narratives. Personal pronouns did not vary either but the second singular personal pronoun “you” did. In particular use of the term I diminished in the seventh interview (although not significantly) whereas use of the word you increased significantly. The total number of cognitive terms (Cog.Mech. such as cause, know, ought) remained stable. However, Insight (think, know, consider) increased significantly. Interestingly, use of words regarding memory (like memory, remember) decreased significantly from the first to the seventh interview. For the emotional terms, Anxiety words (e.g., nervous, afraid, tense) increased, whereas Sadness words (e.g., grief, TABLE 2. Means and SDs of LIWC Categories in the First and Seventh Narratives First Narratives Categories Word count % Word captured Io (I) Tu (singular you) Lui/Lei (he/she) Noi (We) Voi (plural you) Essi/Loro (they) Anxiety Range Sadness Cog.Mech Insight Memory Past tense Present tense Future tense Conditional/conjunctive

Mean

SD

Seventh Narratives Mean

SD

4818 2053 3624 2450 65.1 3.3 64.6 3.1 6.47 1.2 5.7 1.16 0.32 0.24 1.2 0.33 3.3 0.67 3.4 0.83 0.83 0.40 0.72 0.23 0.17 0.14 0.09 0.08 0.73 0.21 0.79 0.31 0.10 0.08 0.72 0.15 0.37 0.18 0.52 0.31 0.75 0.12 0.22 0.17 5.42 1.07 5.75 1.22 0.9 0.31 1.9 0.35 1.9 0.12 0.6 0.2 5.7 0.89 3.9 1.5 5.5 1.4 7.6 1.6 0.05 0.04 0.10 0.09 0.31 0.19 0.89 0.21

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W/MW Test NS NS NS NS 0.01 NS NS NS NS 0.05 NS 0.05 NS 0.05 0.05 0.01 0.05 NS 0.05

cry, sad) decreased. Verbs were used in the past tense to a significantly lesser extent and were used more in the conjunctive/conditional form. Counting words and word categories in a text entails an interpretation or interpretative hypotheses that can be better applied if these words are reinserted into the context from which they were taken. We therefore explored the phrasal contexts where these words were located using T-Laboratory software. We focused on the phrasal contexts of these categories that entailed more of a qualitative analysis than the word counting to be able to provide a more definite meaning to the quantitative occurrence of the categories. This kind of exploration can help to better understand the sense of each text indicator and the different way of narrating life story in the first and seventh narrative.

Cognitive Terms Memory, Remember, and Like The first narratives seem to be centered on the theme of memories and on the strain of remembering: Then okay, I remember that I had friends there in Signa, I had female neighbors like that…(Narrator 1). Okay, I remember the surprise parties that they gave me or anyway that we organized, or the animation that there was there. …(Narrator 3). Okay, then from my childhood I also remember the horse trips that we did. We went to the mane`ge, always to Signa. …(Narrator 8).

Think, Consider In the seventh narratives the narrators reflected more on their memories and attributed a different meaning to these. This is also expressed by the verb to “think” or “consider.” Two phrasal contexts extracted from the first and the seventh narrative of Narrator 4 exemplify this: First narrative. I was never sporty as a child. I played soccer. Soccer has never interested me much, I have never had the physique and I wasn’t even good at it. Seventh narrative. Considering things well, before I liked soccer and I didn’t play that badly, I ran instead. Now I don’t run anymore, but I like playing soccer. …). Narrator 5 makes a similar reflection. First narrative. I don’t remember any affectionate gesture from my father. Seventh narrative. Lately if I think, I think back to when I was little. Often when my father took me fishing comes to mind. When we were alone together I felt that he loved me.

Present Tense The present tense in the seventh narratives was mainly used in 3 different ways. It may have been used to claim general statements. For me friendship would be to always have someone who manages to understand you and who is always there for you, both when you are happy and when you are sad and who doesn’t mind giving you a hand. (Narrator 7). At other times narrators used the present to describe an event which occurred in the recent past (during the laboratory period) but narrated as if it were happening in the present. I find myself here again writing in front of the Arno river. It’s just me and the river and while I have my pen in hand I think about your words, dear doctor, which later became almost like a friend to me in that I am recounting my life and that which makes up Elena. (Narrator 9). The present tense may also have been used to describe a present, actual situation in comparison to the past. © 2010 Lippincott Williams & Wilkins


So now my heart is better, much better than before, I am happier, I appreciate the things I have more; before I didn’t, if only before… now I am more willing to struggle to achieve something, before I gave up straight away, that’s it. (…(Narrator 1).

Conjunctive or Conditional Verb Forms In the seventh narratives, conjunctive or conditional verb forms were used to express dreams and desires. These were also connected to the use of the present tense (general statements). I always aspired to become a doctor, …. if you were to ask me how do you see yourself in 10 years time I dream of myself with the white coat ready to lift those in need up. …(Narrator 2). A wish of mine would be to be surrounded by loyal friends, who are my friends…. In fact, in the future in my life I would like to be surrounded by sincere people. …(Narrator 6).

Singular You The use of singular you was 3-fold. It served to stress or remind the interviewer about something that had already been recounted, to address the interviewer to help her to understand, and to quote a direct past conversation between the narrator and other people. Interesting, in all these cases the verb of the sentence is in the present tense. I told you for me it’s a bit of a private thing, for me religion is to have a belief… Many times it serves to resolve certain why questions, to find the answers. …(Narrator 4). I’m someone, like I told you before, who in times of pain always finds the will to go forward again. Eva says to me “How do you do it? You are great!”, …(Narrator 5). From January to now, he just gave me a million and a half, in 5 months, you think about what a hellish life I have had.. …(Narrator 9). Sometimes I became angry too because taken up every day with these children, especially when it was summer when this one cried and that one wanted the thing. It was hard, because there are 2 and a half years between them so you think how tiring. …(Narrator 3). Now I’ll set the scene for you: we don’t have a lounge room, we have a lounge room and kitchen in the same room, we have a table and a couch and a piece of furniture here in front on the right and just behind is the stove. I had hung up the washing inside the house and he was here and he said “you have broken my balls,” …(Narrator 2). My dad came to get me and I was really unwell and he took me to Pratolino, and … I don’t even know how to describe it to you …(Narrator 7).

DISCUSSION The first aim of this study was to assess whether participating in an autobiographical laboratory, such as that which was devised by the authors, would improve psychiatric inpatients’ social functioning. Given the brief period of our intervention (autobiographical laboratory lasted approximately 2–3 months) we did not expect neither a modification in the diagnosis nor a discharge from the center; however, medical staff agreed in considering them as substantially changed by this experience. Comparison between the 2 administrations of the SFS before and after the autobiographical laboratory showed inpatients’ improvement in all the areas explored by the scale. Moreover, 4 of them found a job. This outcome is consistent with our hypothesis and with all those studies that assume that autobiographical narrating is an important tool for patients’ mental health. The second aim of this study was to assess changes in inpatients’ way of narrating. This second aim is connected to the first because it evaluates whether possible changes in narrating might be © 2010 Lippincott Williams & Wilkins


consistent with changes in inpatients’ social functioning. Text analysis showed how narrators moved from a narrative that was more focused on the memory of the past (an “I” that remembered events which occurred in the past) to a narrative more similar to a conversation. This is evidenced by a greater use of “you,” by verbs used in the present, and by lower use of words meaning “memory process.” Moreover, the last narratives were enriched with “insight” terms and the use of verbs in the conjunctive form. Finally, patients shifted from feelings of sadness to feelings of anxiety. Overall, these indexes are consistent with the hypothesis of a double change in narrative. The first change is in relation to narrative as a text. Narrators were more centered on the analysis of the present and on the world of possibility (the conjunctive). The autobiographical laboratory and the act of narrating, reading, and renarrating their life story lead them to move from the past to the present where they considered their projects, dreams, and delineated their world view. Linguistically, the use of the conjunctive is a good tool to express the world of possibility in comparison to the world of past actions. Nevertheless, the narrative also changed as discourse, that is as the act of narrating (Bruner, 1990). In fact the act of narrating, observed in the fifth narratives, seems to reflect a change in the narrator-interviewer relationship. This is evidenced by the use of singular you, the present tense, and by less use of memory words. As we have shown through our examples, the narrators used singular you to address the interviewer to help her to understand, and to stress and repeat specific points, asking her to put herself in their shoes (you think about what a hellish life I’ve had; so you think how tiring), thereby creating both a physical and psychological scene of the event (Now I’ll set the scene for you: we don’t have a lounge room…). In this latter example, the narrator was more in the present, less interested in remembering and more interested in reminding, and interested in helping the interviewer to understand. Our study was not experimental, where the influence of single variable is assessed. As such, we are not able to evaluate the influence of the Center’s therapeutic rehabilitative program or the extent to which the autobiographical laboratory may have interacted with the center’s activities. Our autobiographical approach (as well as that proposed in Smorti et al., 2008) is interconnected with other health practices performed in a mental health center like the one in the present study. This interconnection occurs not only because an external operator (the autobiographical interviewer) participates in the medical staff’s activities but also because participation in an autobiographical laboratory may encourage narrators to take into account, and reflect on, their present situation in the center. By doing so, narrators may come to integrate different aspects of their experiences. In a similar way, we are not able to assess the degree to which the production of “The book of my life” that represented the end point of the laboratory (though not its main aim) may have affected the narrators’ improvements. What we propose with this study is an approach that must be considered globally. That is, one which includes all possible interconnections with other variables that are present in the system. Therefore, significant changes in the social functioning scale can be attributed to the whole experience, which enabled better reorganization of memories, better comprehension of one’s own life event, and greater trust in being listened to by someone. Further studies, which could also be conducted using control groups, would be useful to disentangle the role of some of these interconnected variables as well as to understand and enhance the effectiveness of this method in relation to the type of diagnosis of the narrators. Ours was a qualitative, pilot study conducted on a small group. Our interpretation of these results is therefore only speculative. However, all our data appear to be consistent. The device used www.jonmd.com | 569


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in our autobiographical laboratory consisted of “narrating-transcribing-reading-narrating.” It was a type of loop that encouraged inpatients to reflect more on their lives and to develop the ability to narrate to someone (the interviewer) and become aware of what had been narrated through a sort of autobiographical dialogue. We consider that, over the course of the laboratory, narrators became closer to the interviewer. Although in the first meeting the interviewer had the task of leading the patient’s autobiographical narrative, by the last meeting the narrator had become an active subject in this dialogue. An alternative explanation is, of course, possible. That is, the way of interviewing changed during the laboratory and this affected the inpatients’ way of narrating. However, this does not affect the basic sense of our results. We believe that the interviewer could not induce a different way of narrating unless the narrators were responsive to this, and willing to change. In other words, it may be that the couple changed during the laboratory. That is the couple interaction changed from an interviewer’s questioning about, and listening to, the patient’s experience to a process of dialogue between the interviewer and narrator, which occurred in the present. Therefore both interpretations (the former based on patient change, and the latter more centered on couple change) are consistent with the improvements noted in the social functioning areas. When the narrator become more active, more reflexive, more in touch with the partner, and more oriented toward exploring the world of possibility (represented by use of the conjunctive) he or she is likely to develop a new way of living his or her life. As Roe and Davidson (2005) pointed out, recovery from schizophrenia requires renewed construction of a narrative. We provided the inpatients with the opportunity to not only be narrators, but also to be coeditors of their story of life book. We did this by providing them with the autobiographical laboratory tool which is based on the production of, and reflection on, texts. There are at least 3 loops (narration, transcription, reading, and renarration) in our protocol that encourage a process of narrating that is renewed by the fact that a person becomes aware of what has been narrated. ACKNOWLEDGMENTS The authors thank the guests of the Meoste Residential Center in Bagno a Ripoli (Florence) for their trust and cooperation, without which this work would not have been possible. They also thank the Center staff, not only for their collaboration and the time dedicated, but also and especially, for their support and enthusiasm demonstrated throughout the course of our work. REFERENCES Alheit P, Bergamini S (1996) Storie di Vita: Metodologia di Ricerca per le Scienze Sociali 关Life Stories: Methodology for Social Sciences兴. Milan (Italy): Guerini Editore. American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th ed). Washington, DC: American Psychiatric Association. Barclay CR (1996) Autobiographical remembering: Narrative constraints on objectified selves. In DC Rubin (Ed), Remembering Our Past: Studies in Autobiographical Memory (pp 94 –125). Cambridge (United Kingdom): Cambridge University Press. Bartlett F (1932) Remembering A Study in Experimental and Social Psychology. Cambridge (United Kingdom): Cambridge University Press. Birchwood J, Smith J, Cochrane R, Wetton S, Copestake S (1990) The social functioning scale. The development a new scale of social adjustment for use in family programs with schizophrenic patients. Br J Psychiatry. 157:853– 859. Brewer WF (1996) What is recollective memory? In DC Rubin (Ed), Remembering Our Past: Studies in Autobiographical Memory (pp 19 – 66). New York (NY): Cambridge University. Bruner J (1986) Actual Minds, Possible Word. Cambridge (MA): Harvard University Press. Bruner J (1990) Act of Meaning. Cambridge (MA): Harvard University Press.

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