Academic journal article American Journal of Psychotherapy

Narrative Incoherence in Schizophrenia: The Absent Agent-Protagonist and the Collapse of Internal Dialogue

Academic journal article American Journal of Psychotherapy

Narrative Incoherence in Schizophrenia: The Absent Agent-Protagonist and the Collapse of Internal Dialogue

Article excerpt

It is widely known that people with schizophrenia have difficulty telling a coherent story of their lives and that this is linked to impoverished function. But what specifically has gone wrong in the narratives in schizophrenia? Is it the case that some elements of narrative remain intact in schizophrenia while others are uniquely affected? To address these questions, we qualitatively analyze the personal narratives of three persons with schizophrenia, which have emerged in psychotherapy. Based on this analysis we suggest that narratives in schizophrenia uniquely fail to situate agency within the narrator resulting in a story that is missing an agent-protagonist. While the narratives we present contain coherent accounts of how others are connected to one another, they fail to evolve into a story about the self as an agent that others could associate with the narrator. We speculate that this may reflect neurocognitively based difficulties maintaining the internal dialogue that propels agency as well as fears that any emergent subjectivity may be appropriated or objectified by others. Implications for psychotherapy are discussed.

While much has been debated about the etiology and course of schizophrenia over the last century, it is widely accepted that persons with this disorder have difficulty ordering and communicating their life stories (1, 2). Such difficulties in self-narration are of clinical and phenomenological significance given their intuitive link with the profound alienation and dysfunction that accompanies schizophrenia (3-5). Without a story about one's condition, or a story of oneself as suffering from, or living with, schizophrenia, how, for example, could someone converse about his or her condition, elicit support, or develop realistic goals? Because personal narratives are so integral to effective agency, their disruption in schizophrenia has come to be regarded as a factor that affects recovery (6) and may be a focal point for psychotherapy and rehabilitation (7-9).

Yet, what has gone "wrong" or "astray" in narratives of persons with schizophrenia? In precisely what ways do the narratives of people with schizophrenia fail to achieve coherence in their own minds as well as in the minds of others? From case studies we know that people with schizophrenia once had a coherent story about themselves (4). What has changed? Is it merely that with the onset of schizophrenia, people can make little sense of anything in general and so their stories fall apart? Or, have specific elements of their narratives failed to "work? " Answers to these questions would appear to be a precondition to theoretical advances in the understanding of social dysfunction in schizophrenia, and the refinement of psychotherapies for people with this condition.

To date we would suggest that there are at best only pieces of answers to the question of what has gone "awry" with narratives in schizophrenia. For instance, we know that self-understanding in schizophrenia may be constricted by identification with the "sick role" (10, 11) and/or lack an appreciation of deficits (12-14). Additionally, others have suggested that narratives in schizophrenia may become increasingly confused as the intensity of affect increases (15-18) or as self-esteem is threatened (19). Examinations of cognitive impairment (20-21) and negative symptoms (22, 23) suggest that the ability to tell one's story may be disrupted by organically based processes that diminish interest in the external world, disrupt the ability to make logical connections, and to connect intention to action. Lastly, from a European phenomenological position others have suggested that schizophrenia reflects an autistic relationship to reality or a lack of "attunement" to others (24).

Thus we know that narratives in schizophrenia may undervalue personal capabilities or symptoms readily apparent to others, and that cognitive limitations, autism, and/or intolerance for pain may limit the overall coherence of the narrative. …

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