Morality, voices, and self at the edge of reality: a narrative analysis of delusional experiences and pathways to care in schizophrenia

Abstract

Delays in seeking help are common in schizophrenia and are associated with negative outcomes. In addition to structural barriers, there is growing evidence that subjective interpretations of psychotic experiences, including delusions, voices, and religious or spiritual attributions, play a crucial role in recognizing symptoms and seeking care. This study explores how individuals diagnosed with schizophrenia describe the onset of psychosis, interpret their experiences, and navigate pathways toward or away from psychiatric care. We conducted semi-structured interviews with 16 individuals with schizophrenia. Data were analyzed using inductive thematic coding and narrative analysis to capture the experiential and interpretive dimensions of psychosis and help-seeking behaviors. We present three interconnected narrative themes that address the research question. First, participants’ experiences revolved around a moral dichotomy involving themes such as God and the devil, good and evil, and power and weakness. Second, participants described ‘nearly real’ sensory experiences, including voices and delusions ranging from familiar to imperative and fearsome. Third, the narratives revealed an ongoing struggle between private and shared realities, involving efforts to define boundaries and regain coherence. These experiential frameworks actively shaped the recognition of symptoms, trust in others, and the timing and direction of seeking help. Psychotic experiences function not only as symptoms but also as organizing narrative forces that influence pathways to care. Narrative-sensitive and metacognitive approaches may improve early engagement and reduce treatment delays.