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SCHIZOPHRENIA: A WAYOFBEING-IN-THE-WORLD 
A thesis presented in fulfilment of the requirements 
for the degree 
of Doctor of Philosophy 
in Nursing 
at Massey University 
Jo Ann Walton 
October 1995 
-----
ii 
ABSTRACT 
This phenomenological study describes what it is like to live with a 
schizophrenic illness and relates the understanding gained from this descripton to 
implications for nursing practice. The participants in the study were ten adults 
who have been diagnosed with schizophrenia, who take regular medication and 
who are living independent lives in the community. Over a period of sixteen 
months they were inteIViewed about the effects of the illness on their everyday 
lives. During this time they explained the challenges and difficulties which have 
faced them, both during and long after the resolution of acute illness. As they 
describe it, schizophrenia is a part of who they are. 
The narrative contained in this thesis presents the participants' stories in 
aggregated fonn, setting their experiences alongside ideas from the early work of 
Martin Heidegger, whose phenomenological writing infonned the analysis and 
interpretation of the data. As the participants explain, schizophrenia has touched 
every aspect of their lives. Living with schizophrenia is shown to affect their 
whole Being-in-the-world. It incorporates Being-with-others, living carefully 
and taking a stand on life. While hoping for a cure, their reality is of living with 
a chronic illness which has major effects on their lives. At the same time the 
participants are shown to define themselves not in tenns of their illness and 
treatment, but in respect of their hopes and dreams and the stance each is taking 
on his or her own life. In this way their existential predicament is highlighted in 
the study. Participants are on the one hand very much like all other people, while 
on the other hand they have to contend with very different concerns than do most 
others. 
In itself the description of the experience of schizophrenia contained in the thesis 
is useful for its potential to increase understanding of the illness by nurses and 
other health professionals. Funher than this, however, the study is shown to have 
implications in tenus of nursing practice and the provision of health care. With 
regard to the seriously mentally ill the data bring into question some of the 
theoretical positions which have held sway in nurSing for many years. The 
research demonstrates that it is practicable to attend to the subjective experiences 
of people who suffer from schizophrenia and to understand their needs and 
desires from the position of fellow human being, without the need for a guiding 
III 
theory from which to interpret what they are saying or what their words "really 
mean." It is argued that relationships between nurses and clients which are based 
on understanding and trust rather than distance hold promise in the care of those 
with schizophrenia. Heidegger's concept of solicitude as care for others is 
addressed in this regard, and is shown to be most appropriate as a basis for 
nursing care in the mental health arena. 
iv 
ACKNOWLEDGEMENTS 
This thesis could never have been written without the help, guidance and support 
of many people. In acknowledging those who have enabled me to complete this 
research I wish first to express my sincere thanks to the study participants, who 
shared their personal stories and gave so generously of their time and their 
hospitality. I am deeply grateful to them for making the study possible, and trust 
that their gift will go some way toward encouraging positive changes in the 
health care that those with schizophrenia receive. 
My supervisors, Professors Norma Chick, Irena Madjar and Linda Chafetz have 
travelled the past four years with me, offering a perfect mixture of advice, 
challenge and gentle encouragement, each in their own way. lowe them each 
particular thanks for their wisdom, time, thoughtfulness and support and for the 
learning they have fostered in me throughout the process of the research. 
I have been supported by too many friends, family members and colleagues to 
name everyone. I would like to express my thanks to my colleagues at Massey 
University, in particular Jan Rodgers for her wise words of advice and 
understanding regarding the loneliness of the PhD process, Marion Pybus who 
was so often there with encouraging words and a listening ear at strange hours, 
Denise Dignam who stood in for me when I was busy elsewhere, and Dorothy 
Clark whose tact, practical skills and sense of humour have helped me surmount 
both technical hurdles and personal setbacks as and when they arose. 
My friends and family have been a constant source of both practicai and moral 
support. They have ensured a constant supply of love, patience, understanding 
and good humour and tolerated my lengthy absences, absent mindedness and 
preoccupation. I wish particularly to thank Charlie. Lynn, Ron and my three 
children, Piers, Erika and Hugh, each of whom has played a special role in my 
completing this work. Thank you all for believing in me, for your commitment 
to the importance of this study and for your central place in giving my life 
meaning. 
Finally I wish to acknowledge the financial support I have received from 
Schizophrenia Fellowship, the Nursing Education and Research Foundation and 
the Massey University Research Fund, and the time made available through the 
Research Award for Academic Women. 
TABLE OF CONTENTS 
ABSTRACf ..................................................................................................... ii 
ACKNOWLEDGEMENTS ............. .................................... ............................. iv 
KEY TO TRANSCRIPTS ................................................................................ x 
INTRODUCflON 
............................................................................................ 1 
Background to the study ....................................................................... 4 
Purpose of the study .............................................................................. 6 
Structure of the thesis ........................................................................... 7 
CHAPTER ONE: 
LITERATURE REVIEW PART I: BACKGROUND ..................................... 9 
Heidegger's Fundamental Ontology ..................................................... 10 
Being-in-the-world ................................................................... 1 1  
Temporality and care ................................................................ 13  
Heidegger's Ontology and the Experience of Illness ............................ 15  
Historical Conceptions of Mental Illness ............................................. 17  
Models of Mental Illness ...................................................................... 24 
The Need to Recognise The Person With The lllness .......................... 28 
The Diagnosis of Schizophrenia ........................................................... 30 
The Contemporary New Zealand Scene ............................................... 32 
Review and Summary ........................................................................... 34 
CHAPTER 1WO: 
LITERATURE REVIEW PART II .................................................................. 36 
The Nature and Incidence of Schizophrenia ......................................... 36 
Epidemiology ........................................................................................ 36 
Aetiology .............................................................................................. 37 
Brain Pathology; Neuropsychology and Neurophysiology .................. 39 
Treattnent .............................................................................................. 43 
Drug therapy ............................................................................. 43 
Psychosocial interventions ........................................................ 46 
Effectiveness and cost of psychosocial 
intervention ................................................................... 49 
Pychiatric Nursing and The Person With Schizophrenia ..................... 50 
Changes in the Health Care System ...................................................... 53 
The Experience of Schizophrenia ............ .......... . ........... . ....... ............... 57 
Fictional and autobiographical accounts of illness . .......... . ....... 57 
The experience of psychotic illness . . ... . ................... ................ . 62 
Insight, acceptance, self monitoring and medication ................ 66 
Life after the resolution of acute illness ... ... ... . .. .......... .... . ....... . 67 
Review and Summary ............. ... .. ......... . . .... ... . ......................... . ....... . . ... 72 
CHAPTER TIlREE: 
STUDY DESIGN AND ME11IOD ............ . .. . . .... ... . . . .. .. .................... .............. . 74 
Aim of the study ...................................................................... .......... ... 8 1  
The choice of the phenomenological method .......... ............................. 8 1  
Recognising assumptions and preconceptions ............. .. ....................... 83 
Access to study participants ............. ........ ......... . ... ......................... . . ..... 85 
Ethical considerations ........................................ . .. : .............. . . . . . . . . . . . . . .... 87 
The study participants ...... . . .. . . . . .. . . .................... .................... . . . . . . . . . . ....... 89 
Data Collection ........ . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . ..... ........... . . . . . . . . . . . . . . ....... .... 92 
Data Analysis ........................................................................................ 96 
Presentation of Findings ....................................................................... 99 
Review and Summary .............................................. ............................. 100 
CHAPTER FOUR: 
BEING-IN-TIIE-WORLD ...................................................................... ......... 101  
Introduction ........................ .............. . ......... ............................... 101 
Realising that one is unwell ......... . ............................................ 102 
Reconceptualising one's Being-in-the-world ............................ 106 
Dlness, Treatment and Being-in-the-world .................... � ......... 107 
Hallucinating ................................................................. 108 
Feelings of unfamiliarity amongst things in the 
world ............................................................................. 1 1 1  
. Being occupied with one's thoughts ............................. 1 16 
The altered body ........................................................... 1 17 
Accepting the need to take regular medication ............. 123 
Coming face to face with the mind-body question ....... 125 
Review and Sununary ........................................................................... 1 3 1  
CHAPTER FIVE: 
BEING-WITI-l-OTIffiRS ................ ......... ............... ........... . . . . . . ... ..................... 133 
Introduction ...... . . ... . . .......................... .... . ..... ... . . .................................. .. . 133 
Living with the prejudice of others .. ...... ............. . . ... ....... ............. .... ..... 135 
Being fearful of others .............. ............................. . . ... . . ... ........ ............. 142 
Feeling uncomfortable in the company of others ....... . ... . ............. . ....... 145 
Staying engaged with others in the world .............. .......................... ..... 147 
Depending on others for. help ....... .... ............... .......... ........................... 149 
Finding others who understand ........... . . . ...... .............. . . ......................... 154 
Being one's-self in the world . ............. . . ........... ..................................... 157 
Review and Summary .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  159 
CHAPTER SIX: 
BEING CAREFUL ............................... ............ ..... ......................................... .. 162 
Introduction .............................. ................ . ........................ . ................... 1 62 
Living circumspectly ....... ............... . . ..................... ...... ...... . . ............ ..... 164 
Maintaining a routine and avoiding stress ... ................. 165 
Taking prescribed medication and refusing street 
drugs ............................................................................. 170 
Monitoring thoughts ....................................... � ............. 175 
Managing fmances ........................................................ 1 80 
Recalling the past and letting it go ....................................................... 1 8 1  
Review and Summary .................... . ...................................................... 1 89 
CHAPTER SEVEN: 
TAKING A STAND ON.LIFE ..............................................................•.......... 191 
Introduction ........................................................................................... 191  
Holding on to hopes and dreams .......................................................... 193 
Taking a stand on one's life .................................................................. 200 
Taking a stand: The individual participants .......................................... 208 
Review and Summary ........................................................................... 212 
CHAPTER EIGHT: 
DISCUSSION ......................•............................................................................ 214 
In'ttOOuction ........................................................................................... 2 14 
Being-in-the-world with schizophrenia ................................................ 214 
The relevance of the phenomenological approach ............................... 216 
Care, solicitude and nursing ......................................................... !. ••••••• 221 
Review and Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  237 
CHAPTER NINE: 
CONCLUSION ................................................................................................. 239 
The limits of the study ............... . ............................. ........................ ..... 24 1 
Suggestions for future research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . .  244 
Concluding Statement .. ...... .. ................................................................. 245 
Appendix I Information sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247 
Appendix II Consent form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  248 
Appendix III Special consent form� . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  249 
Appendix IV Glossary of drugs . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  250 
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  253 
x 
KEY TO TRANSCRIPTS 
The following information explains the meaning of abbreviations and 
conventions used in the presentation of research findings, particularly where 
excerpts from participant interviews are included in Chapters Four to Seven. 
Names: 
Italics: 
All names used to refer to study participants, their family or 
friends, or to health professionals, are pseudonyms. Excerpts from 
participants' interviews are identified by pseudonym, interview 
number and page reference to the transcription, ego (Lucy 2, p. 5). 
Where sections of interview data are reported, the participants' 
words are given in italics. 
(plain type) in interview excerpts the researcher's words are given in plain type 
inside parentheses. 
(parentheses) included in sections of participant speech indicate such things as 
the actions of a participant, ego (laughs), or the name of a place 
such as a hospital which has been removed for reasons of 
confidentiality . 
[square brackets] 
are used when a clarifying or explanatory comment has been 
added by the researcher. 
indicates a pause contained in the original material 
. .//.. material edited out