Establishing and sustaining dialogue in individual psychotherapy
Authors: Lysaker Paul H. , Lysaker John T. 
Published: February 2013

In this chapter, we have suggested that a dialogical account of the self may help us think differently about the goals and even technical requirements of an integrative psychotherapeutic approach to schizophrenia. In particular, we think that psychotherapy for schizophrenia should in part be understood as an effort to reignite intra- and interpersonal dialogue. The hope is that by empowering dialogical capacities, clients will cease to experience themselves as sites of diminishment and regain the sense that they are dynamic centers of insight and action.

At the level of technique, a dialogically informed psychotherapy for schizophrenia should take into account how the client’s self-organization has been compromised by schizophrenia. The thought is that each mode of self-organization requires somewhat different treatment, even though certain techniques are appropriate for all. On the whole, the rule is, begin with whatever dialogical resources are available to the client. With clients suffering from barren self-organizations, the therapist should focus upon their ability to perceive and recall the world of their experience, cultivating it, and then focus on ways in which clients are protagonists within the events they perceive. Because monological self-organizations are characterized by delusional perceptions, in these instances, therapy instead should provide empathic observations of the affects such perceptions provoke. The goal is similar, however: namely, to disclose to clients that, despite the apparent unquestionable authority of these thoughts, they nevertheless have their own affective responses to them, responses that often indicate a desire to live in non-monological ways. Building in the spaces that experience evidences, the therapist can then employ the techniques of cognitive behavior therapy to further weaken the grip of delusions and allow clients to experience them as contextualized phenomena with which they can cope. Finally, with those caught in cacophonous self-organizations, the therapist should collect and present whatever clients reveal about themselves, which may require the therapist to translate universal statements (‘people are angry’) into particular ones (‘you are angry’). The goal here is to help clients find themselves within whatever self-positions quickly enter into and disappear from their self-presentations. The next step involves mutually constructing a narrative that weaves these self-positions and the contexts of their emergence into a life that clients recognize as their own.

While these approaches to different modes of self-organization are notable, they should be viewed as additions to a more basic dialogical approach to psychotherapy for schizophrenia. At its most general, an integrative psychotherapy for schizophrenia, pursued through the lens of dialogism, wishes neither to provide clients with surrogate life narratives, nor remain silent in the presence of their self-presentations. If dialogical processes are going to be sparked and strengthened, their first-person dimensions must be recognized and cultivated. This is pursued in part through re-presenting the self-presentations of clients in order that they might be able to encounter and respond to that disclosure more richly than was previously possible. In order to keep clients focused upon their own place in and contribution to the fates they describe, the therapist should address clients with a stress upon the second-person aspect of their remarks, namely, the ‘you’ who might be attending a basketball game, feeling angry, or struggling with a roommate. The stress invites clients into the therapeutic dialogue, and as another ‘I’. As we argued in Chapter 3, communication builds upon our organism’s reflexive capacities, instituting a reflective dimension within character-positions, and enabling us to pursue the more general activity of reflective dialogue. A therapeutic stress upon the second-person, which continually references thoughts, feelings, and actions to the client, repeats that building process in an effort to expand the first-person capacities of clients, both in and beyond the therapeutic setting.

As the process of deepening and broadening dialogical processes evolves, the therapist continues to respect the first-person dimensions of the client’s plight by remaining oriented towards a mutual understanding of the basic concepts that organize emerging life narratives. In other words, the expert language of systematic psychology is not allowed to tell clients who they are. Instead, they are encouraged to articulate their own sense of self as it is disclosed to them in the reflections that therapy enables, as well as through the course of their lives. Of course, like everyone, clients will rely upon terms that they did not generate ex nihilo, but that reliance will be one that they grow into through sustained reflection.

We should stress that we are in no way suggesting that dialogical theory can turn psychotherapy into a ‘cure’ for schizophrenia. Rather, the goal is to enable people to live effectively with their illness, the threat of stigmatization, and the like. Our claim is that (a) improved dialogical capacities should allow people with schizophrenia to address their illness and its attendant problems in a manner that approximates how others address problems when psychosis isn’t present, and (b) that dialogically inflected psychotherapy for schizophrenia helps brings this about. We claim the latter because in all three of the cases discussed, the clients in question, namely, Grieg, Glass, and Purcell, experienced, over the course of their therapy, decreases in symptoms, improved psychosocial functioning, and the re-emergence of a sense that they were something of a protagonist in the course of their lives. Not that problems did not persist, including symptoms associated with schizophrenia, which merited continued treatment, but having those problems ceased to be the sole, defining feature of their lives, or of whom they took themselves to be.