The Psychotherapy of Schizophrenia through the Lens of Phenomenology: Intersubjectivity and the Search for the Recovery of First- and Second-Person Awareness
Stanghellini, Giovanni, Lysaker, Paul H., American Journal of Psychotherapy
Phenomenological analyses suggest that persons with schizophrenia have profound difficulties with meaningfully engaging the world and situating a sense of self intersubjectively, which leads to the experience of self as absent. In this paper we explore the implications of this view for understanding the workings and potential of individual psychotherapy. Following an examination of individual psychotherapy transcripts for over 60 persons with schizophrenia-spectrum disorders we offer four principles for psychotherapy and provide clinical vignettes to exemplify these points. We suggest that the psychotherapy of persons with schizophrenia may be conceptualised as a "dialogical prosthesis" that helps individuals recover past selves then kindle internal and external dialogue, which partially enables a sense of the self to emerge. The therapeutic process consists of assisting persons to move towards recovery by providing an intersubjective space where they can evolve the first-person perspective of themselves and the second-person perspective when encountering others.
Persons with schizophrenia are widely observed to have profound difficulties with meaningfully engaging the world and in situating a sense of self intersubjectively. They may be able to form a coherent view of the world, but paradoxically, experience their selves as absent from the world and relationships with others. Assertions of such profound diminishments in self-experience in schizophrenia are not a modern invention but can be found in the works of Bleuler and Kraepelin, dating about 100 years ago. Bleuler (1911/1950), deeply concerned with cataloging the discrete manifestations of schizophrenia, noted: "If disease is marked the personality loses its unity" (p 9). And further, "everything may seem different; one's own person as well as the external world ... in a completely unclear manner so that the patient hardly knows how to orient himself either inwardly or outwardly . . .". The person "loses his boundaries in time and space'" (p 143). Kraepelin devoted far less time to this problem perhaps because he believed that this condition reflected the destruction of the self. He noted in the first sentence of his 1919 (2002) discussion of treatment of the condition: "Dementia praecox consists of a series of states, the common characteristic of which is a peculiar destruction of the internal connection of the psychic personality" (p. 3).
While revolutions in the physical and social sciences have dramatically expanded our knowledge of the signs, symptoms, and pathophysiology of schizophrenia, some of the most extensive explorations of the alterations in self-experience have been conducted by phenomenologically oriented researchers and theoreticians. In this paper we explore these phenomenological examinations to develop a psychotherapy that attends to self-experience in schizophrenia. We first offer a brief overview of phenomenology, its methods, and the insights it offers into disruptions in self-experience in schizophrenia. Next, we explore how these insights might help in understanding the process that unfolds in a psychotherapy session. We offer four principles for a psychotherapy informed by phenomenology, and we discuss thoughts regarding how it may differ from other paradigms. Lastly, we note future projects.
PHENOMENOLOGY AND ITS METHODS
Broadly defined, phenomenology is the science of the subjective. Its basic concerns are to explore what is it like to be in a certain state of mind (e.g. to be sad or to hear voices) and what the personal meaning of that certain state is (e.g. what it means to the individual to be sad or to hear voices). Phenomenology also seeks to describe the meaningful organization of a person's experiences, expressions, and behaviours, pointing to the individual's narrative understanding. Narrative understanding brings together the scenario of action with that of consciousness to make sense of the others' behaviours and expressions. …