Abstract
While cognitive behavioral approaches have been shown to help some individuals with schizophrenia, these approaches may be limited when working with patients with impairments in the metacognitive abilities required to form complex and integrated representations of themselves and others. In response, this paper explores the possibility that a key to working with patients with relatively impaired self-reflectivity lies in explicitly focusing on a patient’s intersubjective experience within psychotherapy. We offer theoretical and empirical support for the assertion that the tolerance and capacity for intersubjectivity is a basis for the development of self-reflectivity in general. We also explore how the fostering of intersubjective processes in psychotherapy might enable some patients to form more complex ideas about themselves and so better ward off delusions in the face of the challenges of daily life. To illustrate these principles we present the case of a patient with tenaciously held delusions and limited capacity for self-reflection. We discuss when and how the therapist’s awareness and verbalization of intersubjective processes within session allowed her and the patient to develop more complex and consensually valid ideas about him as a being in the world, which then assisted the patient to achieve improvements in a number of domains in his life.
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References
Allen, J., Fonagy, P., & Bateman, A. (2008). Mentalizing in clinical practice. Washington: American Psychiatric Press.
Aron, L. (1996). A meeting of minds. Hillsdale: Analytic Press.
Atwood, G. E., Orange, D. M., & Stolorow, R. D. (2002). Shattered worlds/psychotic states: A post-cartesian view of the experience of personal annihilation. Psychoanalytic Psychology, 19(2), 281–306.
Barber, C. R., Morrison, K. R., & Gabbard, G. O. (2012). Addressing challenges in individual psychotherapy with delusional patients: A case study. Journal of Contemporary Psychotherapy, 42, 63–67.
Bateman, A. (2000). Integration in psychotherapy: An evolving reality in personality disorder. British Journal of Psychotherapy, 17(2), 147–156.
Bateman, A., & Fonagy, P. (2008). Eight year follow up of a patient treated for borderline personality disorder: Mentalization-based treatment versus treatment as usual. The American Journal of Psychiatry, 165(5), 631–638.
Beebe, B., Knoblauch, S., Rustin, J., & Sorter, D. (2005). Forms of intersubjectivity in interpersonal/relational perspective. The International Journal of Psychoanalysis, 90(2), 347–361.
Brent, B. (2009). Mentalization based psychodynamic psychotherapy for psychosis. Journal of Clinical Psychology, 65(8), 803–814.
Bromberg, P. M. (2009). Truth, human relatedness and the analytic process: An interpersonal/relational perspective. International Journal of Psychoanalysis, 90, 347–361.
Brüne, M., Dimaggio, G., & Lysaker, P. H. (2011). Metacognition and social functioning in schizophrenia: Evidence, mechanisms of influence and treatment implications. Current Psychiatry Reviews, 7(3), 239–247.
Buck, K. D., & Lysaker, P. H. (2009). Addressing metacognitive capacity in the psychotherapy for schizophrenia: A case study. Clinical Case Studies, 8(6), 463–472.
Clarkin, J. F. (2012). An integrated approach to psychotherapy techniques for patients with personality disorder. Journal of Personality Disorders, 26(1), 43–62.
Cortina, M., & Liotti, G. (2010). The intersubjective and cooperative origins of consciousness: An evolutionary-developmental approach. The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 38(2), 291–314.
Critchfield, K. L., & Benjamin, L. S. (2006). Integration of therapeutic factors in treating personality disorders. In L. G. Castonguay & L. E. Beutler (Eds.), Principles of therapeutic change that work (pp. 253–271). New York: Oxford University Press.
Davis, L. W., Eicher, A. C., & Lysaker, P. H. (2011). Metacognition as a predictor of therapeutic alliance over 26 weeks of psychotherapy in schizophrenia. Schizophrenia Research, 129(1), 85–90.
Dickerson, F. B., & Lehman, A. F. (2011). Evidence-based psychotherapy for schizophrenia: 2011 update. Journal of Nervous and Mental Disease, 199(8), 20–26.
Dimaggio, G., & Lysaker, P. H. (2010). Introduction. In G. Dimaggio & P. H. Lysaker (Eds.), Metacognition and severe adult mental disorders: From basic research to treatment (pp. 1–10). London: Routledge.
Dimaggio, G., Salvatore, G., Fiore, D., Carcione, A., Nicolò, G., & Semerari, A. (2012). General principles for treating the overconstricted personality disorder. Toward operationalizing technique. Journal of Personality Disorders, 26(1), 63–83.
Dimaggio, G., Semerari, A., Carcione, A., Nicolo, G., & Procacci, M. (2007). Psychotherapy of personality disorders. London: Bruner Routledge.
Dimaggio, G., Vanheule, V., Lysaker, P. H., Carcione, A., & Nicolo, G. (2009). Impaired self- reflection in psychiatric disorders among adults: A proposal for the existence of a network of semi independent functions. Consciousness and Cognition, 18(3), 653–664.
Fonagy, P., Bateman, A., & Bateman, A. (2011). 2011. The widening scope of mentalizing: A discussion psychology and psychotherapy: theory, research and practice, 84, 98–110.
Frith, C. D. (1992). The cognitive neuropsychology of schizophrenia. Sussex: Lawrence Erlbaum Associates.
Furlan, P. M., & Benedetti, A. (1985). The Individual psychoanalytic psychotherapy of schizophrenia: Scientific and clinical approach through a clinical discussion group. The Yale Journal of Biology and Medicine, 58, 337–348.
Gilbert, P. (1989). Human nature and suffering. New York: Guilford.
Grant, P. M., Huh, G., Perivoliotis, D., Stolar, N. M., & Beck, A. T. (2012). Randomized trial to evaluate the efficacy of cognitive therapy for low functioning patients with schizophrenia. Archives of General Psychiatry, 69, 121–127.
Hasson-Ohayon, I. Integrating cognitive behavioral-based therapy with an inter- subjective approach: Addressing metacognitive deficits among people with schizophrenia. Journal of Psychotherapy Integration (in press).
Hasson-Ohayon, I., Walsh, S., Roe, D., Kravetz, S., & Weiser, M. (2006). Personal and interpersonal perceived control and the quality of life of persons with severe mental illness. Journal of Nervous and Mental Disease, 194(7), 538–542.
Jaffe, J., Beebe, B., Feldstein, S., Crown, C. L., & Jasnow, M. D. (2001). Rhythms of dialogue in infancy: Coordinated timing in development. Monographs of the Society for Research in Child Development, 66(2), 1–132.
Kingdon, D. G., & Turkington, D. (2004). Cognitive therapy of schizophrenia. New York: Guilford Press.
Lafargue, G. (2010). L’expérience subjective de l’effort volontaire dans la schizophrénie: Approche neurophénoménologique. L’évolution Psychiatrique, 75(3), 421–433.
Lafargue, G., & Franck, N. (2009). Effort awareness and sense of volition in schizophrenia. Consciousness and Cognition, 18(1), 277–289.
Laing, R. D. (1978). The divided self. New York: Penguin Books.
Lichtenberg, J., Lachmann, F., & Fosshage, D. (1992). Self and motivational systems: Toward a theory of technique. Hillsdale: Analytic Press.
Lysaker, P. H., Buck, K. D., Carcione, A., Procacci, M., Salvatore, G., Nicolò, G., et al. (2011). Addressing metacognitive capacity for self reflection in the psychotherapy for schizophrenia: A conceptual model of the key tasks and processes. Psychology and Psychotherapy: Theory, Research and Practice, 84(1), 58–69.
Lysaker, P. H., Carcione, A., Dimaggio, G., Johannesen, J. K., Nicolò, G., Procacci, M., et al. (2005). Metacognition amidst narratives of self and illness in schizophrenia: Associations with insight, neurocognition, symptom and function. Acta Psychiatrica Scandinavia, 112(1), 64–71.
Lysaker, P. H., Glynn, S. M., Wilkniss, S. M., & Silverstein, S. M. (2010). Psychotherapy and recovery from schizophrenia: A review of potential application and need for future study. Psychological Services, 7(2), 75–91.
Lysaker, P. H., & Gumley, A. (2010). Psychotherapeutic and relational processes and the development of metacognitive capacity following five years of individual psychotherapy: A case study of a man with psychotic symptoms. Psychosis, 2(1), 70–78.
Lysaker, P. H., & Lysaker, J. T. (2010). Schizophrenia and alterations in self-experience: A comparison of six perspectives. Schizophrenia Bulletin, 36(2), 331–340.
Lysaker, P. H., Roe, D., & Buck, K. D. (2009). Recovery and wellness amidst schizophrenia: Definitions, evidence and the implications for clinical practice. Journal of the American Psychiatric Nurses Association, 16(1), 36–43.
Peri, T. (2008). Psychodynamic therapy and cognitive behavioral therapy—a possible integration? Dialogs, 22(2), 135–142. (In Hebrew).
Raffard, S., D’Argembeau, A., Lardi, C., Bayard, S., Boulenger, J. P., & Van der Linden, M. (2010). Narrative identity in schizophrenia. Consciousness and Cognition, 19(1), 328–340.
Rector, N. A., & Beck, A. T. (2002). Cognitive therapy for schizophrenia: From conceptualization to intervention. Canadian Journal of Psychiatry, 47(1), 39–48.
Roe, D. (2001). Progressing from patienthood to personhood across the multidimensional outcomes in schizophrenia and related disorders. Journal of Nervous and Mental Disease, 189(10), 691–699.
Rosenbaum, B., & Harder, S. (2007). Psychosis and the dynamics of the psychotherapy process. International Review of Psychiatry, 19(1), 13–23.
Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance: A relational treatment guide. New York: Guilford Press.
Salvatore, G., Dimaggio, G., & Lysaker, P. H. (2007). An intersubjective perspective on negative symptoms of schizophrenia: Implications of simulation theory. Cognitive Neuropsychiatry, 12(2), 144–164.
Salvatore, G., Dimaggio, G., & Semerari, A. (2004). A model of narrative development. Psychopathology and implication for clinical practice. Psychology and Psychotherapy: Theory, Research, and Practice, 77(2), 231–254.
Salvatore, G., Lysaker, P. H., Procacci, M., Carcione, A., Nicolò, G., Popolo, R., et al. (2012). Vulnerable self, poor understanding of others’ minds, threat anticipation and cognitive biases as triggers for delusional experience in schizophrenia: A theoretical model. Clinical Psychology and Psychotherapy., 66(1), 85–106.
Salvatore, G., Procacci, M., Popolo, R., Nicolò, G., Carcione, A., Semerari, A., et al. (2009). Adapted metacognitive interpersonal therapy for improving adherence to intersubjective contexts in a person with schizophrenia. Clinical Case Studies, 8(6), 473–488.
Searles, H. (1965). Collected papers of schizophrenia and related subjects. New York: International Universities Press.
Seikkula, J., Alakare, B., & Aaltonen, J. (2001). Open dialogue in psychosis II: A comparison of good and poor outcomes cases. Journal of Constructivist Psychology, 14(4), 247–265.
Sensky, T., Turkington, D., Kingdom, D., Scott, J. L., Scott, J., Siddle, R., et al. (2000). A randomized controlled trial of cognitive behavioral therapy for persistent symptoms in schizophrenia resistant to medication. Archives of General Psychiatry, 57(2), 165–172.
Silverstein, S. M. (2007). Integrating Jungian and Self-Psychological perspectives within cognitive-behavior therapy for a young man with a fixed religious delusion. Clinical Case Studies, 6(3), 263–276.
Silverstein, S. M., & Bellack, A. S. (2008). A scientific agenda for the concept of recovery as it applies to schizophrenia. Clinical Psychology Review, 28(7), 1108–1124.
Stanghellini, G. (2004). Disembodied spirits and deanimated bodies. Oxford: Oxford University Press.
Stern, D. N. (2000). The interpersonal world of the infant: A view from psychoanalysis and developmental psychology. New York: Basic Books.
Stolorow, R. D. (1999). The phenomenology of trauma and the absolutisms of everyday life: A personal journey. Psychoanalytic Psychology, 16(3), 464–468.
Thewissen, V., Bentall, R. P., Oorschot, M., Campo, J., van Lierop, T., van Os, J., et al. (2011). Emotions, self-esteem, and paranoid episodes: An experience sampling study. British Journal of Clinical Psychology, 50(2), 178–195.
Tomasello, M., Carpenter, M., Call, J., Behne, T., & Moll, H. (2005). Understanding and sharing intentions: The origin of cultural cognition. Behavioral and Brain Sciences, 28(5), 675–691.
Trevarthen, C. (1998). The concept and foundations of infant intersubjectivity. In S. Braten (Ed.), Intersubjective communication and emotion in early ontogeny (pp. 15–46). Cambridge: Cambridge University Press.
Yusupoff, L., & Tarrier, N. (1996). Coping strategy enhancement for persistent hallucinations and delusions. In G. Haddock & P. Slade (Eds.), Cognitive behavioural interventions with psychotic disorders (pp. 86–102). London: Routledge.
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Lysaker, P.H., Buck, K.D., Fogley, R.L. et al. The Mutual Development of Intersubjectivity and Metacognitive Capacity in the Psychotherapy for Persons with Schizophrenia. J Contemp Psychother 43, 63–72 (2013). https://doi.org/10.1007/s10879-012-9218-4
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DOI: https://doi.org/10.1007/s10879-012-9218-4