“Schizophrenia is characterized by the profoundly diminished ability to experience and represent one’s life as an evolving story” (Lysaker & Lysaker 2006). Disorganized communication about facts, affects and thoughts is involved in disability and a cause of anguish, and a sense of self that lacks depth. There is a lostness of the self amidst an evolving life, and a sense of being an object of social control. The narratives are impoverished.
The article cited is interesting because it provides for a model of schizophrenia that allows us an idea about how we can work towards a functioning psychotherapeutic alliance with clients who aren’t able to easily provide a clear narrative or dialogue.
Since the work of psychotherapy involves also narratives, how and what can be understood in order to overcome the obstacle of the lack of ability in the client to form coherent narratives?
Dialogical Theory of the Self is used to understand the typology of the experience of self in schizophrenia.
Barren, monological and cacophonous narratives in schizophrenia
The authors asked these questions:
- How could someone lose a sense of him or herself amidst a life where there was formerly coherence?
When one’s sense of self appears to be perishing, just what is it that seems to be vanishing (Lysaker & Lysaker, 2001)?
The answer to understanding this is the dialogical models of the self as written by Dimaggio et. al, 2003, Hermans 2004, Nietzsche 1966. That our sense and story of ourselves are part of inner dialogues of different self positions.
It is to be assumed that (p. 59) :
(1) narratives in schizophrenia may become impoverished when processes that allow for the shifting hierarchies within the self are compromised, and
(2) that the loss of sense of self may fundamentally involve the experience of the loss of dialogue.
Thus impoverished narratives may be reflections of diminished dialogical processes rather than merely weak stories.
Forms of narrative impoverishment and the sustenance of dialogue in psychotherapy
Lysaker and Lysaker suggests that other than forcing the client into narrating cohesively, more attention should be paid to the here-and-now relationship between client and therapist.
The client who has no stories to tell, has difficulty putting into words or bringing to the mind, events and people from the past experiences. The client can be encouraged to describe his/her experiences in the therapy room and his/her relationship with the therapist. The therapists encourages the client on, by sharing his/her own experiences.
If the relationship can be narrated it seems that other relationships might subsequently be narrated as well – leading ultimately to richer narration of internal feelings and conflicts.
For clients who get stuck in monologues, the therapist can bring the client back to the here-and-now by asking what is being experienced as the stories are being told. The therapist can continually make statements or ask questions that encourage the client to relate his/her narratives to his/her experiences in the present.
(W)ith the monologue it may be more important to begin by understanding the suffering of a self that is dominated by a limited number of themes. This could include empathic reflections about how specific thoughts take control and make it impossible for the client to think of anything else. By reflecting on the weight of a delusional theme on the daily life and social relationships, the therapist may avoid agreement or disagreement with a delusion or obsessive theme while building the relationship.
Only after the contact through empathic listening is made, and the client is able to relate his/her experiences of the narrated themes, the therapy can move into the more cognitive approach of reality checking these themes.
From a dialogical perspective we reason that this cognitively-based process may diminish the power of the dominant self-positions and allow other self-positions to begin to contribute to the conversation.
In the case of the cacophonous narratives, the central methodology is the continual mirroring and reflection of what the client is saying at the present moment. In the midst of the fragmented talk, there are pieces of self positions that, with the therapist’s validation, will take foothold.
In this manner independent self-positions might be thought to gather strength to the point where they the can again participate in internal conversations.
Relating to Gestalt Therapeutic Process
Taking the psychotherapeutic relationship to the here-and-now is a very strong feature presented in this article. This is also a major principle in gestalt therapy practice. We also get to appreciate how useful gestalt therapy can be for working with clients diagnosed with schizophrenia.
The other aspect mentioned in this article that I find is closely related to gestalt therapy, is that of phenomenology. Although the word is not mentioned, it is implicit when we bring to the awareness the experiences of creating the dialogue, while not getting sucked in by the content of the narratives. The therapist is handed the task of observing what is happening in the session, and not only focussed on what is being said.
Like most humanistic therapies, unconditional positive regard is the foundation of the work, which requires time and also patience.
Read also : Christopher Bollas on Mental Pain
Lysaker, P. H., & Lysaker, J. T. (2006). A typology of narrative impoverishment in schizophrenia: Implications for understanding the processes of establishing and sustaining dialogue in individual psychotherapy. Counselling Psychology Quarterly, 19(01), 57-68.