Narrative Impoverishment in Schizophrenia: Lysaker & Lysaker

“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.

Read about Notes: Bakhtin’s Polyphonic Novel and the Dialogical Self

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:

  1. How could someone lose a sense of him or herself amidst a life where there was formerly coherence?
  2. 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

Bibliography

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 Quarterly19(01), 57-68.

Research: The Psychotherapeutic Alliance in Research

Interdependent factors that make an alliance:

  • *the agreement between patient and therapist on the tasks and goals of treatment and
  • *the affective bond between patient and therapist.

Ruptures

Refer also to the 3RS manual on ruptures here.

Ruptures are understood as: misunderstanding events, impasses, alliance threats and markers of enactments.


A rupture is a deterioration in the alliance, manifested by

  1. a lack of collaboration between patient and therapist on tasks or goals, or
  2. by a strain in the emotional bond.

Although the word “rupture” connotes a major breakdown in the relationship, the term is also used to describe minor tensions of which one or both of the participants may be only vaguely aware. Ruptures can be obstacles to treatment and can contribute to patient dropout.

Resolution of Rupture as Opportunity for Therapeutic Change

Successful resolution of a rupture can serve as a corrective emotional experience (Alexander & French, 1946), providing a powerful opportunity for therapeutic change

Recognizing the negative impact that unresolved ruptures can have on
treatment outcome, and realizing that these ruptures can go unnoticed by the therapists research is done that is centered around the investigation of whether integrating rupture resolution techniques can improve the efficacy of a particular treatment.

The chapter in this reference gives a detailed account of the kind of research that has been done, that works on the alliance rupture and repair, with the goal of improving probability of training therapists to focus on the alliance.

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Safran, J. D., Muran, J. C., & Eubanks-Carter, C. (2011). Repairing alliance ruptures. Psychotherapy, 48(1), 80-87.
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Barber, J. P., Khalsa, S. R., Sharpless, B. A., Muran, J. C., & Barber, J. P. (2010). The validity of the alliance as a predictor of psychotherapy outcome. The therapeutic alliance: An evidence-based guide to practice, 29-43.

Empirical studies that have shown that alliance is correlated to good outcome:

Horvath, A. O., & Bedi, R. P. (2002). The alliance. In J. C. Norcross (Ed.), Psychotherapy relationships that work (pp. 37–70). New York: Oxford University Press.

Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology, 68, 438–450.

Samstag, L. W., Batchelder, S. T., Muran, J. C., Safran, J. D., & Winston, A. (1998). Early identification of treatment failures in short-term psychotherapy: An assessment of therapeutic alliance and interpersonal behavior. Journal of Psychotherapy Practice and Research, 7, 126–143.

Samstag, L. W., Muran, J. C., Wachtel, P. L., Slade, A., Safran, J. D., & Winston, A. (2008). Evaluating negative process: A comparison of working alliance, interpersonal behavior, and narrative coherency among three psychotherapy outcome conditions. American Journal of Psychotherapy, 62, 165–194.

Tryon, G. S., & Kane, A. S. (1990). The helping alliance and premature termination. Counselling Psychology Quarterly, 3, 233–238.

Tryon, G. S., & Kane, A. S. (1993). Relationship of working alliance to mutual and unilateral termination. Journal of Counseling Psychology, 40, 33–36.

Tryon, G. S., & Kane, A. S. (1995). Client involvement, working alliance, and type of therapy termination. Psychotherapy Research, 5, 189–198.

Reference

Eubanks-Carter, C., Muran, J. C., & Safran, J. D. (2010). Alliance ruptures and resolution. The therapeutic alliance: An evidence-based guide to practice, 74-94.

Index of this book:

I. Critical Studies of the Therapeutic Alliance

  1. Alliance Theory and Measurement 7 Robert L. Hatcher

  2. The Validity of the Alliance as a Predictor 29 of Psychotherapy Outcome Jacques P. Barber, Shabad-Ratan Khalsa, and Brian A. Sharpless

  3. The Alliance over Time 44 William B. Stiles and Jacob Z. Goldsmith

  4. Qualitative Studies of Negative Experiences 63 in Psychotherapy Clara E. Hill

  5. Alliance Ruptures and Resolution 74 Catherine Eubanks-Carter, J. Christopher Muran, and Jeremy D. Safran xiv

Contents II. Practice and the Therapeutic Alliance

  1. A Psychodynamic Perspective 97 on the Therapeutic Alliance: Theory, Research, and Practice Stanley B. Messer and David L. Wolitzky 7. An Interpersonal Perspective on Therapy 123 Alliances and Techniques Lorna Smith Benjamin and Kenneth L. Critchfield 8. The Therapeutic Alliance 150 in Cognitive-Behavioral Therapy Louis G. Castonguay, Michael J. Constantino, Andrew A. McAleavey, and Marvin R. Goldfried 9. A Functional Analytic Psychotherapy (FAP) 172 Approach to the Therapeutic Alliance Mavis Tsai, Robert J. Kohlenberg, and Jonathan W. Kanter 10. The Therapeutic Alliance 191 in Humanistic Psychotherapy Jeanne C. Watson and Freda Kalogerakos 11. Therapeutic Alliances in Couple Therapy: 210 The Web of Relationships Adam O. Horvath, Dianne Symonds, and Luis Tapia 12. Therapeutic Alliances and Alliance Building 240 in Family Therapy Valentín Escudero, Laurie Heatherington, and Myrna L. Friedlander 13. The Therapeutic Alliance in Group Therapy 263 William E. Piper and John S. Ogrodniczuk III. Training Programs on the Therapeutic Alliance 14. Developing Skills in Managing 285 Negative Process Jeffrey L. Binder and William P. Henry Contents xv 15. Training in Alliance-Fostering Techniques 304 Paul Crits-Christoph, Katherine Crits-Christoph, and Mary Beth Connolly Gibbons 16. Developing Therapist Abilities to Negotiate 320 Alliance Ruptures J. Christopher Muran, Jeremy D. Safran, and Catherine Eubanks-Carter 17. Coda: Recommendations for Practice 341 and Training Brian A. Sharpless, J. Christopher Muran, and Jacques P. Barber