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How aging individuals with schizophrenia experience
the self-etiology of their illness: a reflective
lifeworld research approach
Tal Araten-Bergman
a
, Hila Avieli
b
, Peli Mushkin
c
& Tova Band-Winterstein
c
a
School of Social Work, University of Haifa, Haifa, Israel
b
Department of Criminology, Ariel University, Ariel, Israel
c
Department of Gerontology, University of Haifa, Haifa, Israel
Published online: 20 Jul 2015.
To cite this article: Tal Araten-Bergman, Hila Avieli, Peli Mushkin & Tova Band-Winterstein (2015): How aging individuals
with schizophrenia experience the self-etiology of their illness: a reflective lifeworld research approach, Aging & Mental
Health, DOI: 10.1080/13607863.2015.1063110
To link to this article: http://dx.doi.org/10.1080/13607863.2015.1063110
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2. How aging individuals with schizophrenia experience the self-etiology of their illness:
a reflective lifeworld research approach
Tal Araten-Bergmana
, Hila Avielib
, Peli Mushkinc
and Tova Band-Wintersteinc
*
a
School of Social Work, University of Haifa, Haifa, Israel; b
Department of Criminology, Ariel University, Ariel, Israel;
c
Department of Gerontology, University of Haifa, Haifa, Israel
(Received 15 January 2015; accepted 10 June 2015)
Objective: In recent years, there are an increasing number of individuals with schizophrenia who are aging within the
general society. Self-etiology of the illness refers to its causal attributions by this population as part of the life review
process. The aim of this paper is to develop knowledge from the perspective of older people with schizophrenia regarding
the self-etiology of their illness. Focusing on the self-etiology of this particular population is useful, to enhance
the understanding of their lived experience in the context of their lifeworld.
Method: The study was carried out using the reflective lifeworld phenomenological approach. In-depth semi-structured
interviews were conducted with 18 aging individuals with schizophrenia followed by analysis for meaning.
Results: Five major constituents of the phenomenon under study À the experience of self-etiology among aging people
with schizophrenia À emerged from the findings: ‘It leaves you to your fate’ À schizophrenia as a decree of fate; ‘I have
sinned against God’ À schizophrenia as a punishment from God; ‘They put something in my coffee’ À schizophrenia
as a result of witchcraft; ‘Her genes are in me’ À schizophrenia as genetic; and ‘She left me and that’s how I got
sick’ À schizophrenia as a result of personal trauma.
Conclusions: The findings show that self-etiology in old age tends to be stable, externally attributed and culturally
oriented, and serves as a central component in the life review process. This is relevant for professionals developing
intervention methods for aging people with schizophrenia.
Keywords: aging; qualitative research; schizophrenia; self-etiology
Introduction
Social changes such as increase in life expectancy, dein-
stitutionalisation and the development of new psychiatric
drugs have led to the integration of aging people with
schizophrenia into the general community (Niimura et al.,
2011). The outcomes of these processes have led to a
close encounter between caretakers and professionals
within the community, and thus call for a wide and com-
prehensive understanding of aging individuals with
schizophrenia perspectives on their life and their illness.
Narrating self-etiology in this advanced stage of life might
serve as a way to accept and give meaning to their lives as
well as to promote more suitable interventions for care-
takers and professionals. Despite the growing emphasis
on understanding self-etiology of individuals with mental
illness (Williams & Healy, 2001), little is known about
the way these beliefs are produced and represented in old
age. The aim of the present article is to describe how
aging people with schizophrenia give meaning to their ill-
ness by using self-etiology in their current lifeworld.
Self-etiology
Self-etiology relates to explanatory models of people’s
causal attributions of illness and health, which are concep-
tualised as part of the inquiry into health beliefs (Baker &
Procter, 2013; Williams & Healy, 2001). Self-etiology is
important because it might influence the individual’s pref-
erences and expectations regarding the course of the illness
or the treatment (Khalsa, McCarthy, Sharpless, Barrett, &
Barber, 2011). The way in which patients understand their
illness is predictive of symptom presentation and promotes
seeking behaviour (Sheikh & Furnham, 2000). It has been
suggested that when psychiatrists and their clients share the
same etiological models for mental illness, the client tends to
be more satisfied with the treatment (Callan & Littlewood,
1998), and might be more likely to comply with it (Bhui
& Bhugra, 2002). Thus, even when caretakers (e.g., pro-
fessionals, family members and friends) and people with
schizophrenia do not agree with the other’s conceptuali-
sation of the condition, it is important for caretakers to
be aware of the cause and nature of the illness as per-
ceived by their clients for the purpose of negotiating
acceptable treatment (Jacob, Bhugra, Lloyd, & Mann,
1998; Shankar, Saravanan, & Jacob, 2006).
In addition, self-etiology of the illness is a central
component in the individuals’ attempt to make sense of
and attribute meaning to the mental illness (Williams &
Healy, 2001). Literature suggests that people tend to seek
an ‘identity’ for their illness (Leventhal & Neren, 1985;
Karp, 1992), and when the identity suggested by the medi-
cal establishment does not resonate well with their subjec-
tive experiences, they continue to seek ‘alternative
identities’, which they perceive as more compelling
(Karp, 1992). Thus, self-etiology gives people with
*Corresponding author. Email: twinters@research.haifa.ac.il
Ó 2015 Taylor & Francis
Aging & Mental Health, 2015
http://dx.doi.org/10.1080/13607863.2015.1063110
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3. mental illness the opportunity to gain some control over
their situation by increasing their understanding of it and
how it is caused (Whittle, 1996).
Etiology and self-etiology of schizophrenia
Numerous causal explanations of schizophrenia have been
offered over the years, each inspired by a different aca-
demic tradition (Walker, Kestler, Bollini, & Hochman,
2004). These etiologies date back to the days of Fromm-
Reichmann (1948), who suggested the controversial and
offensive concept of the ‘schizophrenogenic mother’ as a
cause of schizophrenia (Harrington, 2012), via the idea of
traumatic life events as a trigger for the illness (Nuechterlein
et al., 1994; Read, Perry, Moskowitz, & Connolly, 2001).
Recent explanations view schizophrenia as a brain disease
caused by several genetic and biological factors (Walker
et al., 2004).
Despite the flow of scholarly explanations regarding
the cause of schizophrenia, little attention has been given
to the etiological explanations provided by people with
schizophrenia (Williams & Healy, 2001). Studies that
explore self-etiology suggest that people who experience
mental illness attribute their condition to a wide range of
causal factors, some of which are inconsistent with tradi-
tional explanations (Elliott, Maitoza, & Schwinger, 2012).
These include lack of faith in God (Baker & Procter,
2013), family conflicts (Read, Magliano, & Beavan,
2013), supernatural causes (Adewuya & Makanjuola,
2008) and other social factors (Holzinger, L€offler, M€uller,
Priebe, & Angermeyer, 2002; Jeffs, 2009).
The studies of self-etiology referring to mental illness
are focused on three main characteristics: cultural context,
external attribution and instability of the explanation over
time (Ghane, 2008). Several studies emphasise the impor-
tance of cultural influence in constructing self-etiology
(Kleinman, 1980). Concepts and values such as the impor-
tance of willpower in determining illness and health in
one’s life (Arkoff, Thaver, & Elkind, 1966), belief in
supernatural powers (Ghane, Kolk, & Emmelkamp, 2010)
and belief in God (Nichter, 1980) may be central to the
way people understand the causes of their illness. The
present study was conducted in Israel, which, like most
Western societies today (Smooha, 2002), is multicultural
and multi-ethnic. Israel’s multiculturalism stems from
two main sources: Jewish immigrants from all over the
world (Al-Krenawi, 2005), internal variation among the
Muslim and Christian Arab and Druze population, and
high degree of difference within the Jewish society in eth-
nicity and strength of religious beliefs (Al-Krenawi &
Graham, 2000). This reality causes current and future
challenges as culture plays a prominent role when one is
affected by a mental illness. This is apparent both in how
the illness is interpreted (Carpenter-Song et al., 2010) and
the way the person copes with and relates to the situation
within the cultural and environmental context (Michie &
Skinner, 2010; Weiss, Shor, & Hadas-Lidor, 2013).
The cultural roots of self-etiology might relate also to
people’s tendency to attribute their illness to external or
internal causes and to those over which the individual
either does or does not have control (Elliott et al., 2012).
Attribution theory argues that explanations for undesir-
able events are most adaptive when they deflect responsi-
bility to external causes outside of one’s control (Heider,
1958; Kelley, 1967; Weiner, 1986). People diagnosed
with mental illness might be motivated to understand the
causes of their condition as external, to protect their self-
concept (Sayre, 2000).
The third characteristic suggests that people with
schizophrenia are highly unstable and tend to change their
self-etiology over the years in accordance with personal
and environmental circumstances (Ghane, 2008). This
claim supports Williams and Healy’s (2001) concept of
‘explanatory maps’, which was introduced as an alterna-
tive to ‘explanatory models’. In their view, individuals’
ideas on illness causation are not sufficiently coherent to
be qualified as ‘models’, but rather form a map of inter-
play of possibilities, according to which people search for
possible illness explanations.
However, the literature that characterises self-etiology
as culturally oriented, externally attributed and unstable
does not examine this phenomenon within the growing
population of aging people with schizophrenia.
Old age and schizophrenia: life story work
and self-etiology
The population of elder persons with schizophrenia is rap-
idly growing, in line with the increased life expectation in
the general population (Cohen et al., 2008; Meesters
et al., 2012). Social changes such as deinstitutionalisation
and the development of new psychiatric drugs have led to
the integration of these aging people into the general com-
munity (Novella, 2010).
Together with this, knowledge regarding schizophre-
nia in old age is limited (Cohen et al., 2008). The tradi-
tional view of the course of schizophrenia has been that of
progressive decline (Berry & Barrowclough, 2009). Yet,
recent studies indicate substantial heterogeneity in the
long-term course of schizophrenia. Whereas chronically
institutionalised individuals with schizophrenia display
progressive worsening in cognitive ability and general
functioning (Harvey, 2005), other community-dwelling
outpatients show stability in the progress of the illness,
which allows better access to their aging experience
(Palmer, McLure, & Jeste, 2001). Studies on these people
with schizophrenia indicate that, in old age, positive
symptoms are reduced (e.g., hallucinations, delusions,
thought and movement disorders) (Belitsky & McGla-
shan, 1993; Davidson et al., 1995), whereas the intensity
of negative symptoms (e.g., flat affect, lack of pleasure in
everyday life, poor executive functioning, trouble focus-
ing or paying attention, etc.) might increase (Cohen,
1990) or decrease (Davidson et al., 1995). Moreover, cog-
nitive deterioration observed in this population is parallel
to the cognitive deterioration in the general aging popula-
tion (Berry & Barrowclough, 2009).
Aging processes are accompanied by life story work
(LSW) (McKeown, Clarke, & Repper, 2006). As people
approach the final years of their lives, they tend to look
back at major life events and revaluate the meaning attrib-
uted to them (Reker, Birren, & Svensson, 2013). Butler
2 T. Araten-Bergman et al.
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4. (1964) pointed out that old people organise their lives
over certain consecutive themes that allow them to resolve
conflicts, deal with the notion of death and create a better
understanding of past events while emphasising some of
them and blurring the meaning of others.
LSW is a term given to biographical approaches in
health and social care that give people the opportunity to
talk about their life experiences (Murphy, 2000). This
approach emphasises the exploration of older people’s
past and present lives, together with them, and particularly
the circumstances which have shaped their experiences.
This ‘story-telling’ process may potentially provide both
old people and practitioners with greater insights into their
needs and aspirations (Johnson, 1976; Elipoulos, 1997)
Thus, exploring the subjective etiological explanations of
old people with schizophrenia may provide extensive
knowledge regarding the way they construct their life
story and give meaning to living with schizophrenia.
Few qualitative studies have focused on the way that
old people with schizophrenia perceive their lives in old
age, including the positive and negative changes brought
by aging (Pentland, Miscio, Eastabrook, & Krupa, 2003;
Shepherd et al., 2012; Shibusawa & Padgett, 2009), feel-
ings of increased vulnerability (Martinsson, Fagerberg,
Lindholm, & Wiklund-Gustin, 2012), loss of dignity and
identity as well as loss of family, friends and other aspects
of ‘normal’ life (Martinsson et al., 2012; Pentland et al.,
2003; Shibusawa & Padgett, 2009) and feelings of hope
and fear regarding the future (Pentland et al., 2003; Shibu-
sawa & Padgett, 2009; Shepherd et al., 2012).
To the best of our knowledge, no studies have focused
on self-etiology of older people with schizophrenia. There-
fore, the purpose of this study was to describe and explore
how aging people with schizophrenia give meaning to their
illness through self-etiology in their current lifeworld.
The study and its method
It has been noted that significant aspects of schizophrenia
cannot be addressed by large-scale quantitative studies
and should be investigated by in-depth qualitative studies
conducted with small samples of participants (Brier,
1988). Therefore, we chose a reflective lifeworld approach
(RLP) based on phenomenological epistemology as
defined by K. Dahlberg, H. Dahlberg, and Nystr€om
(2008). This approach focuses on the lifeworld, which
forms the basis for understanding people’s lives, health,
suffering and well-being (Johansson, Ekebergh, & Dahlberg,
2008). The key principle of this phenomenological
approach is openness to the experience of aging with
schizophrenia, thus facilitating the capture of their life-
world in their own terms without reference to external cri-
teria of ‘what it is like’ to be an aging person with
schizophrenia (Ashworth, 1996).
Participants and sample
The research sample included 18 participants, 11 men and
7 women. Purposeful sampling was used (Patton, 2002)
according to the following criteria: current age over 60,
diagnosed with schizophrenia before the age 40, living in
the community, with adequate verbal, cognitive and men-
tal state capacities to respond to face-to-face in-depth
interviews. The participants’ age ranged from 60 to
69 years, with a mean age of 63. The mean age of onset
was 22.3. Most of the participants were single or divorced
at the time of the interviews and were living in hostels,
and some were in a sheltered employment arrangement.
Table 1 presents a summary of the participants’ socio-
demographic characteristics.
The final sample size (18 participants) was determined
according to Morse’s principles (Morse, 2000), which
Table 1. Participants’ socio-demographics.
Name Age
Age of
onset Sex
Family
status
No. of
children
Place of
birth Education Occupation Residence
Gregory 69 25 Male Divorced 0 Russia Academic Sheltered employment Hostel
Ofir 62 22 Male Divorced 2 Israel Elementary Freelance gardener Hostel
Naomi 62 20 Female Single 0 Iraq High school Sheltered employment
Ester 63 28 Female Single 0 Israel Elementary Retired
Menashe 62 22 Male Single 0 India High school Sheltered employment Hostel
Isaac 63 22 Male Divorced 2 Romania High school Sheltered employment Hostel
Moses 67 30 Male Divorced 2 Iraq High school Occupational club Hostel
Zack 66 23 Male Divorced 0 Algeria High school Sheltered employment Hostel
Boris 60 19 Male Single 0 Russia Academic Sheltered employment Hostel
Varda 60 18 Female Single 0 Israel High school Sheltered employment Hostel
Jacob 65 25 Male Single 0 Libya High school Sheltered employment Hostel
Haim 61 16 Male Single 0 Romania High school Sheltered employment Hostel
Aaron 65 30 Male Divorced 3 Australia Academic Sheltered employment Hostel
Shula 60 n/a Female Divorced 3 Israel High school Sheltered employment Independent
living
Zipora 61 12 Female Single 0 Israel Elementary Sheltered employment Hostel
Mazal 68 15 Female Single 0 Libya High school Doesn’t work Hostel
Rachel 62 28 Female Divorced 0 Argentina Academic Doesn’t work Hostel
Saul 60 25 Male Single 0 Israel Academic Doesn’t work Hostel
Aging & Mental Health 3
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5. include several factors: the quality of data, the scope of
the study, the nature of the topic and the amount of useful
information obtained from each participant. According to
Morse (2000), the sample size in phenomenological stud-
ies is determined by the richness and depth of the data
gathered from the informants. In this study, not all the
appointments with the participants materialised into com-
plete interviews. Some participants changed their mind
and abandoned the interview. Others withdrew their con-
sent after the interview had been completed, so their inter-
views were excluded from the study. In addition, some
participants had difficulty verbalising their experience.
When 18 participants had been interviewed, recurring
content indicated that saturation had been reached.
Data collection
Phenomenological interviews were conducted to allow self-
expression of aging people with schizophrenia regarding
their self-etiology (Dahlberg, Drew, & Nystr€om, 2001).
At the beginning of the interview, we asked several
questions about the experience of living with schizophrenia:
Can you tell me about yourself and your illness? Can you
share with me the story of the illness through the years?
How would you describe your life with the illness through
the years? The purpose of these questions was to form a pic-
ture of the background to the phenomenon. An additional
question then focused on the specific phenomenon under
study: When you think about your illness today, what do
you think might have caused it? The answers to these ques-
tions were followed up by questions such as: ‘What do you
mean by that?’ ‘When you review your life, what explana-
tions do you provide for your illness?.’ The aim of the fol-
low-up questions was to attain deeper information by
encouraging the participants to reflect on the phenomenon.
Procedure
The data presented in this article were drawn from a wide-
scale study carried out by a research team at the Univer-
sity of Haifa. It comprised two head researchers (one with
a doctorate in gerontology and one with a doctorate in
social work) and a graduate gerontology student who is a
certified social worker, specialises in mental health and
rehabilitation, and is familiar with this population.
Potential participants were located by professional
managers of rehabilitation facilities, who also initially
approached the participants. One of the researchers, who
conducted the interviews, subsequently telephoned the par-
ticipants, to introduce herself, ask for their consent to be
interviewed and to set a time for the interview. This intro-
ductory telephone conversation was essential to inform the
participants of the topic of inquiry and to establish an ini-
tial rapport and trust. The participants chose the location
for the interview. Its duration depended on their individual
needs and abilities; usually from 1À2 hours. All interviews
were audio-recorded and transcribed verbatim.
Throughout the study, each researcher kept a personal
reflective journal that documented thoughts and feelings
that arose during the interview (Ahern, 1999; Tufford &
Newman, 2012).
Analysis of the findings
The analysis process was based on the principles
described by Dahlberg, et al. (2001). The aim of this
approach is to allow the description of the essence and
meaning structure of the phenomenon of the lived experi-
ence of self-etiology among aging people with schizo-
phrenia. In addition, this type of analysis emphasises
various everyday life experiences of aging with schizo-
phrenia in relation to the self-etiology as reflected in the
study participants’ spontaneous life review.
The RLP is based on the concept of openness, which
consists of several facets: the remaining open to how the
phenomenon calls to be expressed, describing or interpret-
ing the phenomenon in context, and commitment to a bri-
dled attitude throughout the process (Vagle, 2014). The
phenomenological analysis characteristics used are flexi-
bility, pliability and back and forth movement between
the whole and the parts, so that the meaning of the parts is
understood in relation to the whole and vice versa.
After reading all the interviews several times to gain
familiarity with the data as a whole, they were broken
down into smaller parts or units of meaning, with the focus
on the phenomenon under study. These units were based
on statements made by participants in the interviews, and
words or phrases mentioned that captured the different
meanings of the phenomenon. Considering variations of
similarities, the parts were then gathered into clusters and
the meaning units were translated into abstractions using
more scientific language (Dahlberg et al., 2001). The clus-
ters were then organised into patterns, which generated a
general structure that is the essence (the core meaning) of
the phenomenon and its constituents (which particularise
the phenomenon as a whole). The interdisciplinary research
group held a discussion to analyse the data, leading to find-
ings from the combined perspective of social work, geron-
tology and mental health rehabilitation. During the
analysis, the researchers maintained an ongoing dialogue
and sought agreement on the interpretation of the lived
experience. Examples of the questions considered are as
follows: How should the participants’ descriptions of their
illness etiologies be interpreted À as a symptom of the dis-
ease (hallucinations) or as a rational explanation? Each
interpretation reflects a different perspective on the etiolog-
ical world as presented by the participant. The team used a
‘bridled’ attitude while discussing each disparity, as sug-
gested by Johansson, Ekebergh and Dahlberg (2009). The
bridling method prevented quick or careless understandings
or the imposition of a definite quality on what is indefinite
(Dahlberg & Dahlberg, 2003).
It should be noted that, because of the uniqueness of
the phenomenon, some of the narratives were expressed
in a brief and refined manner, which limited the richness
of the data but still provided access to the participants’
lived experience.
Ethical considerations
The research was approved by both the Israeli Ministry of
Health and the ethics committee of the University of Haifa
in Israel. The gathered information remains confidential,
according to Patton’s recommendations (2002). From the
4 T. Araten-Bergman et al.
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6. outset, the study topic was considered highly sensitive
(Dickson-Swift, James, Kippen, & Liamputtong, 2007; Lee
& Renzetti, 1993), and special provision was made to ensure
informed consent and confidentiality (Corbin & Morse,
2003). Each participant signed a letter of consent, which
included a promise to safeguard their privacy. Identifying
details were changed to preserve confidentiality. The inter-
views were saved on the author’s personal computer, which
allowed no external access. In addition, special attention
was paid to emotions expressed by the interviewee, and the
interviewers ensured that the interviewees were not left with
unresolved bad feelings. The interviewers utilised their pro-
fessional experience in social work and mental health to cre-
ate candid interaction with the interviewees. This was
achieved by expressing sincere interest in their experience,
thereby encouraging the participants to express sensitive
personal topics in a setting that emphasised comfort and
respect (Dickson-Swift et al., 2007).
Findings
The lived experience of people with schizophrenia seems
to change as a consequence of their current stage of life. It
seems that as people with schizophrenia get older, the
search for an etiology for their illness becomes more cen-
tral to their lives. Examining their accumulated stock of
knowledge about their illness experience might be an
opportunity for organising a coherent life narrative. This
new perspective in old age might provide an answer to the
lifelong question of ‘Why did it happen to me?’ Aging
people with schizophrenia seem to perceive the etiology
of their illness in the context of their life stories rather
than according to the accepted medical explanation. As a
result of this experience, they can feel that they have
become ‘lone wolves’ À seeking alone for understanding
not provided by anyone else. The different self-etiologies
suggested by aging people with schizophrenia may be
viewed as strategies to achieve a meaning to their lives to
create closure and to reduce ambiguity and the feeling
that life is an unsolved riddle. These strategies can be
divided into five major constituents: (1) ‘It leaves you to
your fate’ À schizophrenia as a decree of fate; (2) ‘I have
sinned against God’ À schizophrenia as a punishment
from God; (3) ‘They put something in my coffee’ À
schizophrenia as a result of witchcraft; (4) ‘Her genes are
in me’ À schizophrenia as genetic; and (5) ‘She left me
and that’s how I got sick’ À schizophrenia as a result of
personal trauma. These constituents represent different
aspects of the phenomenon and together comprise the
phenomenon as a whole. Moreover, the different constitu-
ents are mutually exclusive and were endorsed by several
participants. The results are based on all the interviews
but individual statements illustrate and highlight the inter-
pretations within each constituent.
‘It leaves you to your fate’ À schizophrenia as a decree
of fate
One way to describe the self-etiology of the illness was
narrating it as their destiny determined by a higher power.
This constituent was endorsed by four participants, and is
illustrated in the following quote:
In Judaism, we believe that God throws you the ”movie“
of your life and tells you that’s how it’s going to be,
whether you like it or not. It leaves you to your fate, it
does not ask you... Now I know that this life is all fate.
(Ofir, 62).
This was not my plan, but what can I do? I’m not religious,
but this is what God wished for me and I have to accept it.
Now that I’m 69, it’s time to accept it. (Gregory, 69)
For many years, I asked myself why; now I believe that it
was written up there. (Zippora, 61).
The use of the ‘movie’ metaphor to explain how God
determined life long ago strengthens the notion that life
and all its difficulties are out of control and that there are
no options of changing it. The term ‘throws you’ suggests
a sense of powerlessness against fate, and that the only
option is to accept it in old age. Insight at this point in life
might enable the participants in this category to under-
stand and make peace with the illness and view it as a part
of God’s bigger plan. It seems that constructing such a
narrative might offer them a type of comfort that is so sig-
nificant in achieving feelings of completion. Moreover,
they reconstruct the basic feeling of powerlessness into
feeling part of a larger abstract and unknown plan.
‘I have sinned against God’ À schizophrenia as a pun-
ishment from God
As in the previous category, (three) participants in this
category attribute their fate to a higher power. However,
whereas participants in the first category emphasise pow-
erlessness against the forces of fate, participants in this
category describe a dialogue between their behaviour and
its results, as illustrated in the following quote:
I’ll tell you the truth, I’ve sinned... Nothing went right for
me... I’ve cursed God and denounced Him. Heaven forbid.
Because I didn’t know what was going on with me... Why
nothing went right for me... that was the problem. I’ve
sinned against Him, Heaven forbid. Now, as I am old, I’m
sure He’ll forgive me one day so I can go to heaven.
(Zack, 66)
I know I behaved badly with my parents and my brothers.
They suffered a lot; maybe that’s why it all happened to
me. I used to curse and hit them when I was young. This is
my punishment. My parents passed away… now I can just
ask God to forgive me for what I did to them. (Boris, 60)
I never believed in anything, not in God, not in the
“karma”, and then they told me I have schizophrenia; this
is how the universe talks to me. (Shula, 60)
The participants in this category describe a chain of
bad events and failures, which they have caused throughout
their lives, leading to the loss of faith in God. Reflecting
back on their lives, they believe that their actions led to the
illness. In that sense, they see themselves as responsible for
the illness, but now, in old age, they seek forgiveness, or
Aging & Mental Health 5
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7. any other way of ensuring a ‘good place’ in the afterlife, by
amending the relationship with God and the universe.
‘They put something in my coffee’ À schizophrenia as a
result of witchcraft
Another self-etiology, relating schizophrenia to witch-
craft, was presented by four participants:
I think I’ve been hexed... I think that’s why I’m sick...
They put something in my coffee... The Rabbi from Jaffa
gave me an amulet. It lasted for two and a half years...
then its power wore off. The Indian woman, she removed
my hex... removed my evil eye... It would last for two
months, but then it came back. (Menashe, 62)
Where I come from, my parents told me it was the witch-
craft of the Gipsies. When my mother was pregnant she
met a Gipsy woman and she cursed her... when I got mar-
ried I thought the curse had gone, but it came back... now
I’m thinking about going to Romania to find a Gipsy Sha-
man to remove the curse. (Haim, 61)
Participants in this category came from a cultural
background that leaves room for magic powers that
impact daily life. Thus, they attribute the schizophrenia to
witchcraft. Since the illness is perceived as a result of
magic, they seek assistance through magic contra-meas-
ures: through someone from the same culture who will
break the hex. In this stage of life, this self-etiology pro-
vides a coherent explanation for the episodic nature of the
illness course by describing the struggle between magic
powers. The ritualistic magic acts enable them to experi-
ence symptom-free periods, thus allowing them to per-
ceive themselves as both ill and healthy.
‘Her genes are in me’ À schizophrenia as genetic
Three participants in this category attributed the schizo-
phrenia to a genetic background, as illustrated in the fol-
lowing quote:
My Mother was old... so they took her to the psychiatric
hospital and I was there too. She was there twice and I
have been there seven times... that’s why it all happened
because my mother was ill and I’m also ill. She was ill
psychiatrically, and I’m also psychiatric. She has been in
a closed psychiatric institute. I met about 30 doctors in
my life from all sorts of hospitals. The doctor that admit-
ted me the first time I was hospitalised already knew my
mother; maybe her genes are in me... (Mazal, 68)
For many years, my grandmother’s illness was kept
secret; nobody talked about it... then I got sick. Once I
heard my father saying to my mother: ‘It’s all because of
your mother’, Now I know what he meant... (Varda, 60)
In biology, I learned about hereditary illness and forgot
about it. Now I don’t know how I could have put it aside
when my mother had a mental breakdown and stayed in
bed for weeks... (Saul, 60)
Participants in this category explore their family his-
tory and create an equation between themselves and their
families of origin. ‘Passing down the torch’ of the illness
becomes a type of family legacy transmitted from genera-
tion to generation. It seems that, in this stage of life, they
accept the ‘family legacy’ of being part of an intergenera-
tional inheritance of illness and its consequences.
‘She left me and that’s how I got sick’ À schizophrenia
as a result of personal trauma
Another etiological explanation connected the onset of the
illness to traumatic life events (four participants), as illus-
trated in the following quote:
So my wife left me... and she took the kids, and I didn’t
see them... not since they were 13... I saw them for half an
hour and then they were gone... difficult, very difficult. I
loved them so much... that is why I became sick... they
left me so suddenly, I tried all sorts of things. I took pills...
I wanted to die. The neighbours called the police... They
brought the emergency medical service and I was hospi-
talised... (Aaron, 65)
I worked for the post office for many years and I was good
at it... and then I got fired. Since then, I haven’t been able
to find another job... I got depressed, so I decided to go to
Israel... and here, in Israel, I became really ill with schizo-
phrenia. (Rachel, 62)
Participants in this category attribute the onset of
schizophrenia to a personal crisis, which became a turning
point in their life course and led to the illness. The crises
described by the participants are a forced break-up from
spouse and children, the loss of a job and immigration,
which led to a mental collapse and sometimes attempted
suicide. These participants perceive the traumatic chain of
events as overshadowing their mental illness. Now, in old
age, they construct a self-etiology in which the lived expe-
rience of the traumatic event stands at the centre of the life
story, while the illness itself is pushed to the background.
Discussion
Facing the adversities of severe mental illness such as
schizophrenia drives people to attempt to make sense of
their illness experiences (Cardano, 2010). The aim of the
present study was to follow self-exploration processes
made by aging adults with schizophrenia, who are
involved with questions regarding the nature and causa-
tion of their illness along the life course. The analysis of
the findings produced a variety of self-etiologies of
schizophrenia: ‘It leaves you to your fate’ À schizophre-
nia as a decree of fate; ‘I have sinned against God’ À
schizophrenia as a punishment from God; ‘They put
something in my coffee’ À schizophrenia as a result of
witchcraft; ‘Her genes are in me’ À schizophrenia as
genetic; and ‘She left me and that’s how I got sick’ À
schizophrenia as a result of personal trauma. They reveal
several conceptual understandings regarding the context
of schizophrenia and aging.
Some authors characterised the self-etiology of people
with schizophrenia as fluctuating, changing rapidly in
6 T. Araten-Bergman et al.
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8. accordance with life’s trajectories (Williams & Healy,
2001). Gahne (2008) claimed that fluctuation in the con-
tent of self-etiology was so severe that participants
changed it during the interview or presented several con-
tradicting etiologies simultaneously. The present study,
which focused on aging people with schizophrenia, does
not support this notion, as the results indicate that partici-
pants presented a holistic and rather coherent view of the
illness etiology. It seems that whereas over the life course,
participants might have changed their perception regard-
ing the cause of the illness (Ghane, 2008), in later life,
they construct a reasonably stable etiology for their ill-
ness, as manifested in their coherent expression during the
interviews. Specifically, none of the study participants
neither changed nor contradicted their explanations during
the interview. It is possible that even though self-etiology
might change over time, it assumes its final form in old
age, thus allowing people with schizophrenia to construct
a coherent narrative of their life with the illness. This
interpretation is in keeping with the life review concept
(Reker et al., 2013). In this stage of their lives, older peo-
ple with schizophrenia perform life review like other older
people. This process includes resolutions of conflicts,
insights regarding life events and better understanding of
past events (Butler, 1964). Thus, life review enables an
identity exploration process that allows people to answer
the question of ‘who am I?’ (Clarke, Hanson, & Ross,
2003). The results of this study suggest that a life review
process might contribute to shaping a stable self-etiology
in old age. Although Butler and others claimed that life
review is a natural process in the lives of all aging people,
our study shows that this process exists within this specific
population of aging people with schizophrenia, but its con-
tent might be different and include self-etiology. It seems
that for aging individuals with schizophrenia, self-etiology
plays a major role in the identity exploration process.
The findings of the present study suggest a gap
between ‘outside’ views on the causes of schizophrenia
and the inside perspectives regarding the etiology of the
illness. Our study indicates that regardless of the prevail-
ing etiological explanation that views schizophrenia as a
brain disease (Walker et al., 2004), participants were far
more likely to mention other types of self-etiology such as
witchcraft, a decree of fate or personal childhood trauma.
This finding echoes Hiedegger’s (1993) view of the phe-
nomenological perspective that provides us with the
‘sense of being there’ based on ‘the things themselves’. It
highlights the awareness of the ‘lived experience’ of eld-
ers with schizophrenia to which self-etiology is central.
Moreover, this notion corresponds with the recovery
model of mental illness (Australian Health Ministers’
Advisory Council , 2013). This approach also focuses on
the lived experiences and insights of people with mental
illness, stressing the importance of personal identities
beyond the constraints imposed by psychiatric diagnosis
(Andresen, Oades, & Caputi, 2011).
Analysing the content of the participant’s explanations
of the illness revealed that most of them attribute the onset
of the illness to external causes. According to attribution
theory, perceiving the cause of an event as internal
intensifies the accompanying emotions, whereas perceiv-
ing its cause as external reduces those emotions (Kelley &
Michela, 1980). Accordingly, individuals with severe
mental illness tend to attribute their mental condition to
external causes beyond their control, such as harsh life
events, thereby decreasing the negative effect of their ill-
ness on their self-esteem (Elliott et al., 2012). Similar con-
clusions were reported in several other studies on this
subject, in which illness was attributed to external causes
such as the death of a significant other (Backer & Procter,
2013), childhood trauma (Elliott et al., 2012), work pres-
sure (Williams & Healy, 2001) and supernatural causes
(Adewuya & Makanjuola, 2008). In line with these find-
ings, it seems that, in old age, external attribution serves
as a means of closure and achieving peace of mind, which
are especially significant for them at this stage of life.
Another aspect of the results relates to the partic-
ipants’ cultural background and its contribution to the
construction of self-etiology. The American Psychiatric
Association has recently recognised the importance of
considering the sociocultural belief system of people with
mental illness and has introduced the term ‘cultural con-
cept of distress’ (DSM-5, 2013). This term refers to ways
in which cultural groups experience, understand and com-
municate suffering, behavioural problems or troubling
thoughts and emotions. Consistent with similar findings
(Lloyd et al., 1998; McCabe & Priebe, 2004; Saravanan,
David, Bhugra, Prince, & Jacob, 2005), the results in this
study suggest that self-etiology is culture-oriented (e.g.,
schizophrenia as a decree of fate, schizophrenia as a pun-
ishment from God, schizophrenia as a result of witchcraft)
and thus should be evaluated in the context of the relevant
sociocultural belief system which is rooted in the partic-
ipant’s lifeworld. It seems that cultural belief systems
interact with the course of the person’s illness to produce
a unique set of self-etiology types. For instance, religious
faith serves as a bridge between the unstable course of the
illness and experiences of lack of personal fulfilment, fail-
ure and loss. In other words, culture-based accounts
enable the participants to narrate a life story that they can
accept and live with while approaching old age.
Limitations and recommendations for further study
The present study was conducted using the phenomeno-
logical approach. To broaden the understanding of the
phenomenon of self-etiology, triangulation can be used by
participatory observation or interviews with family mem-
bers and caretakers of old people with schizophrenia.
In addition, the sample of the present study was lim-
ited to participants qualified by cognitive, verbal and
attention skills that were sufficient for expressing percep-
tions and emotions during a relatively long interview.
Consequently, the present study failed to reveal the unique
voice of persons with schizophrenia who have lower cog-
nitive, verbal and attention capabilities. Future research
might overcome this challenging limitation, using desig-
nated research tools, facilitating meaningful interaction
with those individuals. In addition, further research is rec-
ommended to focus on individual differences and
Aging & Mental Health 7
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9. characteristics, such as gender, age and ethnic origin and
their effect on the construction of self-etiologies.
Finally, self-etiology of individuals with schizophre-
nia was explored retrospectively, from the viewpoint of
old age. To encompass wider aspects of the subject, it is
suggested to supplement the present research by longitudi-
nal studies addressing various life events in vivo, rather
than retrospectively.
Practical implications
The findings of the present study reveal a gap between
medical and personal perspectives regarding the etiology
of schizophrenia. It seems that people with schizophrenia
might feel misunderstood, alone or even patronised by their
professional caretaker as a result of this gap, which should
thus be addressed by practitioners. The present study sug-
gests that old people with schizophrenia have developed
some solid self-etiology that helps them make sense of
their illness, challenges the notions of professional power
and focuses on the needs of people with mental disorders.
The new reality in which people are aging with schizo-
phrenia calls for the development of specific interventions
by professionals. The life review process appears to be
prevalent amongst aging people with schizophrenia, as is
the case in the general aging population. The construction
of self-etiology is central to the life review process and
thus we recommend that practitioners use this powerful
tool to facilitate the expression of thoughts and feelings
regarding major life events and causal explanations of the
illness. This will enable both practitioners and individuals
with schizophrenia to reach closure by identifying together
their unique narrative regarding life with schizophrenia.
Disclosure statement
No potential conflict of interest was reported by the authors.
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