In this section, similarities and differences between students and patients are discussed in relation to the research questions.
How do patients and students describe their relationships and interactions?
Both students and patients described relationships as highly important. However, while students described in detail both qualitative and quantitative development in their relationships, patients mostly described an unchanging state of loneliness, short-term relationships or professional relationships, and little or no positive development regarding relationships.
There can be several ways to understand these differences. First, students and patients described clear differences in their motivation for relationships. Most students described their motivations for friendship as intrinsic and coherent. They talked about “having fun,” used cognitive concepts of “friends” and “families,” and weighed the mutual responsibility of friendship. Patients often mentioned external motivation for their relationships, such as wanting help from professionals or having the ability to learn from other patients’ experiences.
If the patient’s relationship to the therapist is “functioning” and the patient gets better, the relationship will be broken because the patient no longer needs it. However, he or she will still want the company of others, and this is especially important as patients may have few or no other relationships. Since these goals are contradictory, it might be problematic for them. Reaching one goal (“getting better”) will cause them to lose another goal (“having comforting company”), so maintaining secure relationships seems incompatible with getting better.
At the same time, they also described an intrinsic motivation for relationships—they enjoyed being with the nurses and other professionals, and talking and spending time with them. Of course, we cannot know if both these descriptions represent patients’ genuine experiences or if they simply replicate social norms. Ringer [
19] has shown that patients often adapt their personal narrative to fit the narrative of the ward. This may be the case here, meaning that patients’ real motivations are intrinsic, but that they feel pressure to focus on the usefulness of the relationships.
Regardless of reasons, patients
did, in fact, focus on this usefulness and did so in describing relationships with other patients—where the social norms of the wards might be less obvious. It is, therefore, possible that what has occurred is an adaptation of their concept of friendship, possibly affected partly by the social norms of the medical system. Some stated directly that therapists or nurses had told them that they should be with others to “work on their anxiety” or that “social relations might be good for their mental health” or for other external motivation. Although there may be truth to these, in regard to mental health, this might not be the best strategy for developing friendships. In a study of healthy adolescents, Ojanen et al. [
20] found that adolescents who enjoyed the intrinsic qualities of friendship would develop more friendships, while those who established friendships based only on extrinsic motivation would lose interest over time. Even if their study is on adolescents, it might be relevant also for development for friendship in adult life. It could be harder for patients to develop friendships outside of professional relationships, since doing things “just for fun” indicating an intrinsic motivation was seldom described in the interviews.
Another striking difference between students and patients is the possibility to develop relationships over time. Students attended the schools much longer than patients remained at the wards and thus had the opportunity to develop lasting and mutual relationships. Most patients described relationships and situations that were fluctuating, and few had long-lasting relationships. Ojanen et al. [
20] found that relationships and skills for building them need time to develop. If all relationships are brief, both skills for making lasting relationships and the motivation to do so may suffer. Most theories of development [
6‐
8] state that consistent, long-term relationships are crucial for developing a secure and consistent sense of self. The students, however, described marked changes in social functioning and capacity for friendship.
Since impairments in social functioning and social cognition are common in patients with psychoses [
21], many programs have been developed to correct cognitive biases [
22]. The students had not received formal cognitive training but reported on development anyway. However, they might have benefitted from long-lasting and intensive social training in a natural environment. Individual Placement Support (IPS) is a method used for helping people with severe and long-term mental illness to function at work [
23]. Instead of the traditional approach of training people first in a separate place, and then trying to transfer the learned skill to the workplace, IPS focuses on training people to do their jobs at an actual workplace, without the need to transfer skills, and this approach has shown better results than the traditional one [
23]. Instead of training in cognitive skills separately, they get intensive and long-lasting practice, with teachers as role models, in real-life situations. This also aligns well with models of development stating that humans are natural social individuals and that all development occurs in social relationships [
6‐
9].
How do patients and students describe themselves, their motivations, and actions?
Both patients and students were receiving or had received psychiatric treatment; most stated that they had a diagnosis or had one earlier and that they were using or had used medication. However, issues such as treatment, medication, and illness had very different focuses in interviews with students and patients, and in their personal narratives; patients described themselves primarily as patients while students used mainly other narrative descriptions.
When asked about their everyday lives, students described a development where they enjoyed new activities and gained mastery, more relationships, and better experiences. They seldom used their illness to explain their actions or emotions (even if some stated that they used to do so earlier), and illness seemed to have little place in their lives and thoughts, suggesting that this was not their main narrative now. Instead, most of them used relational, social, or pedagogic explanations for their actions, emotions, and development, indicating that the schools’ focus on these themes had been internalized by the students.
Patients’ descriptions were quite different, with a much greater focus on their illnesses. In the interviews, both their descriptions of everyday life and their attributions and explanations of things that were happening were related to illness. They spoke of few topics other than illness, even when asked detailed questions about their lives. They also described little personal development or their development in the role of patient. Some mentioned that they wanted to do certain activities but had to wait until they were better; treatment of their illness had the highest priority.
Students, by contrast, did not wait. They described doing activities now; they had access to many more activities than did patients and mentioned these activities as important. It seemed that the different activities affected the students in several different ways. All students said that learning itself was important and, that it was crucial for them to feel that they could learn new things and experience mastery and growth. The students’ descriptions had a much greater focus on development, learning new things, increasing mastery, making changes, and personal growth. These are all central parts of the concept of flourishing and related to well-being and growth in humans [
24]. Students also described that learning new skills gave them new opportunities. For example, if you can cook, you can invite a friend to dinner; if you know something about poetry, you can engage in conversation at a poesy festival. This aligns well with research findings that better social functioning and ability to engage in pleasant activities are connected to increased self-esteem and reduced depression in patients with severe mental illness [
25].
The students also described that some of the theoretical and philosophical topics were important for them, and that reading about people in different life situations, for example, reading philosophy and history, gave them a broader view about their own lives and their problems. Dowrick et al. [
26] found that attending reading groups and the content of the literature has significant effects on the outcomes of patients with depression [
26], and reading groups have improved cognitive and psychosocial functioning of patients with psychosis [
27]. This may indicate that not only participating in an activity but also the content of the activity might have affected the students.
Furthermore, not only the number of available activities but also motivation for activities differed between students and patients. Both students and patients talked about going for walks with others. Students did so in classes related to “nature” or “my community” or as part of art classes. The purpose of these walks was to learn about nature or their community/city or to paint. Descriptions of the walks were typically related to the purpose; they described the kinds of birds, flowers, or buildings they saw; the weather; what they learned; or what they painted. In addition, they often mentioned positive emotions and motivation, such as having fun or enjoying nature—all descriptions focusing on a motivation directly linked to the activity.
Patients described going for walks as part of treatment. Some stated that they enjoyed this, especially spontaneous trips alone with a nurse, when they could talk about their problems. They also went on walks together as a group, often framed as exercise. This seemed to be a less-popular activity, but the patients described that “exercise is good for treating mental disease.” The curative element, therefore, seemed to be the main purpose for these walks. Even when asked specific questions, they would seldom describe anything else about the trip (what they saw, the weather, etc.) but rather would repeat the extrinsic motivation of “treating mental disease.” Studies regarding the effects of physical exercise on severe mental illness [
28] show that exercise, in fact, is beneficial, even if its effects on severe mental illness are less profound than for depression.
In this context, however, it is probably more important to consider the differences between the students’ descriptions of intrinsic motivation compared to the patients’ extrinsic motivation. Studies have repeatedly shown that extrinsic motivation is often less durable and weaker and might lead to lower creativity and engagement [
29]. This might explain some of the differences between patients and students in regard to engagement. Students’ motivation seemed to be more intrinsic and internalized, and therefore easier to maintain over time. Patients, by contrast, often had a more extrinsic motivation (curing the disease), and this would be more difficult to maintain, especially when the reward (being cured) was not reached. Patients with schizophrenia tended to have an external locus of control and attributed their health to external factors associated with lower recovery [
30]. These findings align well with the descriptions given by the interviewed patients but not with the students’ descriptions, indicating that the problem might lie in the social narrative surrounding the informants and not in their individual functioning.
Another difference between patients and students was the patients’ use of contradictory statements, which were not used by any student. There may be different interpretations of these phenomena. Ringer’s research [
19] showed that patients often had to adapt their descriptions to align with the narrative of the ward, and that might be the case here—that patients say what they feel is expected of them, for instance, that they should work with their development, even if this does not align with reality. This interpretation fits well with the interesting shift in perspective in the statement quoted earlier, where patients start with a first-person perspective,
“I am working” and then shift to a third-person perspective,
“one is working…,”, indicating that this perhaps is not about him or her but about what he or she thinks is the expected thing to say. On the other hand, there are elements in the framing that could encourage this use of contradictions and especially lack of consistency. Most patients said that plans were often altered, and that there was little consistency between plans and reality. If the patients had learned to describe the world as it ought to be instead of how it is, it is natural that they would also use this pattern in their own descriptions.
Patients also tended to describe themselves in a passive and objectifying manner. Again, this may be a result of adapting to social norms at the ward, as Ringer described [
19]. Ricoeur [
31] explores the issue of self and identity, and states that all utterances must be interpreted in the context in which they appear, including who the person is talking to. When talking to a researcher about experiences with nurses, patients might felt a pressure to confirm to a norm indicating that others besides themselves know better what they need. They might also have been acclimated to a need to “prove” their statements by referring to professionals with greater authority then themselves. This means that the patients’ environment does not support and respect their personal autonomy and integrity, but rather encourages a process where others are experts about their lives. This is confirmed by many statements made by patients [
15] indicating that, often, they felt disrespected by health professionals, or that their complaints or wishes were not taken seriously. Some of them also seem to have internalized this view, stating that the professionals “know better,” while others complained about not being taken seriously. Students, by contrast, did not describe themselves in an objectifying manner but instead as active agents. They used much of the interview time to describe their plans, wishes, dreams, choices, interests, and preferences. They stated that they were happy, had found themselves, had more energy, accepted themselves, were more confident, and lived better lives. They also said that they feel respected and accepted at school, and that the teachers take their statements, wishes, and needs very seriously.
The parental acceptance-rejection theory [
32] states that there exists a general, cross-cultural connection between children’s perceived acceptance or rejection by their parents and their psychological adjustment. This theory aligns well with the descriptions of patients and students indicating that the difference in self-perception in the informants, as well as adjustment and happiness, are as least partly connected to how the students felt met by teachers/health professionals.
How do patients and students describe their personal development?
There were clear differences between patients and students regarding descriptions of development. With few exceptions, most patients described stagnation or even worsening of their situation. By contrast, all students described some kind of development representing clinical recovery, personal recovery, or both [
10].
Patients described receiving much more treatment than students did, especially repeated short-term interventions. These descriptions align well with research that finds sense of self to be a core challenge of schizophrenia [
1,
2] and may also be relevant to other severe mental illnesses [
3]. If the core problem for patients is related to sense of self, focusing on short-term interventions based mostly on symptoms and stabilization is likely to have limited long-term effects, just as the patients described.
The students’ diagnoses were similar to those of the patients, but they described much more development. They talked about less treatment but more stable and mutual relationships, respect, acceptance, and meaningful activities [
15]. Again, these descriptions agree with the theories of sense of self as the core problem; thus, focusing on personal development might be more beneficial for reducing symptoms than treating symptoms directly.
Listening to the students’ descriptions, their experience of relationships, sense of self, and development seemed to interact in a constant process. This continuing development through long-term, mutual relationships and participation in meaningful activities closely resembles many of the classical theories for human development [
6‐
9] describing the development of identity as a process of constant interaction and relationships that develops over time. This differs significantly from the patients’ descriptions of short-term interventions and aligns with the hypothesis of personal development as more crucial than treatment of symptoms.
A striking difference between students and patients was that patients talked much more about “usefulness” and treatment, while students described joy, fun, and liking their classmates. Many informants in both groups discussed problems starting in early childhood [
15]. Several researchers state that early developmental trauma may negatively affect cognitive development and that play is important for repairing the impacts of trauma and re-establishing the conditions in which the brain can again learn and develop [
33‐
35]. The constant focus on treatment and usefulness might reinforce the tendency in the traumatized brain to stay in what Siegel [
34] describes as the “plane of activation.” A brain in this state will typically be locked into old solutions and negative thinking. To reach what he describes as the “plane of possibilities,” where the brain feels safe and able to playfully consider new possibilities, Siegel states that safety, time, and room for playfulness are necessary—the same features students mentioned as important for them.
There were also marked differences in the interviewees’ descriptions of hope. Patients in general described having little hope for the future, while all students talked about their hopes and plans for the future. Snyder’s Hope Theory [
36] defines hope as bi-dimensional, combining agency and pathways. In regard to this theory, the patients’ lack of hopes and plans is natural, given the low agency and lack of pathways they describe. By contrast, the students’ self-acceptance, personal engagement, and experiences of mastery may facilitate their beliefs in further development in the future.