The Psychotherapy of Schizophrenia

through the Lens of Phenomenology:

Intersubjectivity and the Search for the
Recovery of First- and Second-Person
Awareness

GIOVANNI STANGHELLINI, M.D.*

PAUL H. LYSAKER, Ph.D.#

Phenomenological analyses suggest that persons with schizophrenia have

profound difficulties with meaningfully engaging the world and situating a
sense of self intersubjectively, whicb 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 examina-
tion of individual psychotherapy transcripts for over 60 persons with schizo-
phrenia-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, whicb partially enables a sense of the self to
emerge. The tberapeutic process consists of assisting persons to move towards
recovery by providing an intersubjective space wbere they can evolve the
first-person perspective of themselves and tbe second-person perspective when
encountering others.

Persons with schizophrenia are widely observed to have profound diffi-

culties with tneaningfully engaging the world and in situating a sense of self
intersubjectively. They may be able to fortn 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.

*Institute of Psychology, University of Chieti (Italy); #Roudebush VA Medical Center and the
Indiana University School of Medicine, Mailing addtess: Roudebush VA Medical Center 116H, 1481
West 10* Street, Indianapolis, IN 46202, email: plysaker@iupui,edu
AMERICAN JOURNAL OF PSYCHOTHERAPY, Vol. 61, No. 2, 2007

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Bleuler (1911/1950), deeply concerned with cataloging the discrete man-

ifestations 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 phenomeno-
logical examinations to develop a psychotherapy that attends to self-
experience in schizophrenia. We first offer a brief overview of phenome-
nology, 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 para-
digms. 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 to-
gether the scenario of action with that of consciousness to make sense of
the others' behaviours and expressions. Narratives are synthesizing
schemes of comprehension that confer a unifying meaningfulness to
seemingly disparate phenomena. This means that narratives are connec-
tions between one person's perceptions, emotions, motivations, desires,
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beliefs, values, and a given action. They are not deterministic cause-effect
explanations, but prohahilistic connections.
Phenomenologically oriented researchers and theoreticians typically
use methods that involve in-depth interrogations of patients about subjec-
tive experiences, and the questions suspend or "bracket" any presuppo-
sitions about the phenomena under investigation, including its normality
or abnormality, its putative causes (and explanations for it), or its noso-
graphical attribution. The phenomenological view we present here about
the worlds that persons with schizophrenia live in is, at least pardy,
empirically grounded on evidence from psychopathological research on
the initial phases of schizophrenia (Gross, Huber, Klosterkooetter & Linz,
1987; Parnas, Handest, Saebye, & Jansson, 2003; Moeller & Husby, 2000;
Parnas, Moeller, Kircher, Thalbitzer, Jansson, Handest, & Zahavi, 2005).
We derive its guiding concepts from phenomenological and developmen-
tal psychology (Parnas & Bovet, 1991; Stern 2000; Rochat 2001). Also, it
is theoretically connected to the neurodevelopmental hypothesis of schizo-
phrenia presented by Marenco and Weinberger (2000) and Parnas, Bovet,
and Zahavi (2002).

PHENOMENOLOGY AND THE LOSS OF SENSE OF SELF IN

SCHIZOPHRENIA
Results of phenomenological investigations suggest that the sense of
loss of self in schizophrenia involves compromised first- and second-
person awareness, leaving affected individuals able only to view themselves
from "the outside". It has been asserted that in schizophrenia parts of the
self, for example, thoughts, feelings, sensations, intentions, which would
usually be sensed as belonging to the self, are objectified or spatialised.
That is, these are felt as existing in an outer space. For instance, thoughts
may be experienced as existing somewhere outside the limits of what
defines the self, and persons with schizophrenia may feel cast away from
their natural seat and able only to contemplate themselves from the outside
or from a third-person perspective. "My first-person life has been lost and
replaced by a third-person perspective" (Parnas, 2000, p. 124). There is a
loss of pre-reflexive, immediate self-awareness, including the feeling of
agency (the sense that I am the source of this thought or movement) and
of ownership or "myness" (the sense that I am experiencing this thought,
emotion, or movement). Individuals may perceive themselves as a mech-
anism that thinks, perceives, and acts but experiences no meaningful
selfhood (Lysaker, Lysaker & Lysaker, 2001; Lysaker, Wickett, WUke, &
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Lysaker, 2003; Lysaker & Daroyanni, 2006; Lysaker, Davis, Jones, Stras-
burger, & Beattie, In press; Sass, 1992).
Beyond disturbances of the first-person perspective, phenomenological
analyses also suggest that the loss of self in schizophrenia also is related to
compromises in the second-person, "I-You", perspective of the social
world (Blankenburg, 1971). Intersubjectivity is the process that takes place
in the second-person or "I-You" encounter. This second person experi-
ence is based in the implicit attunement between oneself and the other
(Parnas & Bovet, 1991), and it is not merely based on the explicit,
encyclopaedic knowledge of shared behavioural rules existing somewhere
in the world. In life without psychosis, understanding of the other is based
on a precognitive, intuitive experience; it is a direct perception of the
others' emotional life and an implicit sharing of a common meanings,
rather than calculated inferences of others' mental states (Stanghellini &
Ballerini, 2002). In people with schizophrenia, this implicit sharing is
compromised, and the resulting attunement crisis leaves only the third-
person perspective, from which they are able to characterize and under-
stand the interpersonal world. The experience of connection with others
can only be experienced as if from outside of the relationship (i.e. from the
third person). In schizophrenia the social world thus loses its characteristic
network of relationships among embodied selves moved by emotions, and
turns into a cool, incomprehensible game (from which the person feels
excluded) the meaning of which is sought through the discovery of
abstract algorithms and elaborate impersonal rules (Stanghellini & Bal-
lerini, 2004).

PSYCHOTHERAPY OF SCHIZOPHRENL\ THROUGH THE LENS

OF PHENOMENOLOGY
While such explorations of the metamorphoses of self- and social
consciousness and their impact on outcome in schizophrenia are illumi-
nating, and make these mysterious experiences less puzzling, the implica-
tions for psychotherapy are yet to be explored. If we accept that schizo-
phrenia involves disruptions in first- and second-person experiences, does
this lead to any new insights into the mechanisms and principles of
psychotherapy? It has long been asserted that psychotherapy may be
profoundly useful to persons with schizophrenia (e.g. Fromm-Reichmann,
1954; Rogers, Gendlin, Kiesler & Traux, 1967; Searles 1965; Weiden &
Havens, 1994), though the reasons why remain a matter of debate. It is
argued, for instance, that psychotherapy can help correct discrete dysfunc-
tional or maladaptive cognitions (Garety & Freeman 1999). On the other
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hand, it may help resolve underlying conflicts, and lead patients to

internalize healthy aspects of the therapist that are necessary for better
function (Karon, 2003). This paper next explores the implications of the
phenomenologically informed view of self-disturbance in schizophrenia on
psychotherapy. First, we ask whether we can observe, during a psycho-
therapy session, a therapist assisting a patient begin to recapture the ability
to engage in first- then second-person experiences. We offer a synopsis and
analysis of a psychotherapy session in which a therapist offers a patient
possibilities for second-person self-experience, which the patient then
uses.
Second, we explore the characteristics, or principles, of a psychother-
apy concerned with assisting individuals in recapturing the ability to
engage in first- and then second-person experiences. We present four key
principles illustrated with clinical vignettes that are based on a review of
transcripts of psychotherapy sessions we conducted with more than 60
persons who were diagnosed (according to DSM-IV criteria) with schizo-
phrenia or schizoaffective disorder. All psychotherapy patients observed
were adults treated under voluntary and routine conditions in an outpa-
tient clinic of a medical centre. The majority of patients were male, aged 25
to 55 years, and all took psychiatric medications.
THE OPENING OF SECOND-PERSON AWARENESS AS ILLUSTRATED WITHIN THE
COURSE OF A SINGLE SESSION
Can a single psychotherapy session assist in the recapture of the ability
to engage in first- and then second-person experiences? To find an answer
we examined the process of a single therapeutic session recorded verbatim.
The patient, Grieg, is a man in his 50s with schizophrenia. Grieg had been
seen by Paul Lysaker in individual psychotherapy for more than four years,
and as detailed elsewhere (Lysaker, Davis, Eckert, Strasburger, Hunter, &
Buck, 2005), has made many significant gains, including improvements in
social function and a reduced use of delusions to explain life events and his
reactions to them. We present a synopsis and a discussion of how the
process that unfolds within one session are attempts by the patient and
therapist to find Grieg's first-person experience and to frame it in the
second person.
Grieg begins the session by stating "things" are "bad". Seeming unable
to discern what was bad, why it was bad, or even the boundaries around
where the badness was, he paused, and finally noted that he was the devil,
that he should go to distant part of the globe where children were starving,
and that he was not out to become king of the United States. He offered
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only the thinnest first-person perspective: "I've had too many bad
thoughts." With this hint of first-person perspective, the therapist next
offered a view in the second-person: "You are feeling bad." Grieg re-
sponded with delusional material about being hated by others years
ago and a vague description of himself in a meaningless and seemingly
unconnected activity.
At this moment, the therapist knew Grieg was experiencing distress,
but there was, as of yet, no clue about was distressing for him. The
therapist, too, saw that Grieg was struggling to experience himself as
someone who was suffering and to see himself as someone to whom
something had happened. Critically, the therapist again offered a view
from the second person: "Something has happened to you." Greig re-
sponded with seemingly unconnected material about buying food for
people who do not become his friends. The therapist now perceived a
theme in the few things Grieg said about himself: he is in distress,
something has happened to him, and people are not his friends. He offered
another view in the second person: "You have no friends." Strikingly,
Grieg acknowledged this as a "problem" he has, and finally, he described
what had happened to him: he tried to help his adult child with a task and
was careless, accidentally destroying a valuable item, which left him feeling
humiliated.
The therapist, seen through the lens of phenomenology, has offered a
second-person view repeatedly. In response, Grieg evolved a first-person
account of an embarrassing event. As the therapist continued to toss out the
statements in a second-person perspective, such as "You feel you can't do
anything right", some vision of the second person begins to be formed by
Grieg. He noted feeling jealous of his child's spouse, and then recognizes how
he makes delusional statements, which insults them. He relayed how his
behaviour hurts them and how, at time, they graciously ignore it. With this
pain admitted, Greig lost the intersubjective stance and bizarre material
reemerged. In response, the therapist again offered more from the second
person, interjecting the word "you" into the conversation in a more immediate
manner: "You find it hard to say that you are angry." Greig seemed to see this
as true of himself and expresses confusion and pain: "But I am not angry at
you . . . But it is true I do find it diffictilt to say that I am angry. ..." As the
session ends, Greig expressed grief about a failed romantic relationship and
others who have left him. The therapist and Grieg shared a sense of sorrow
constructed intersubjectively during the session.
What is striking here is that seemingly unrelated symbols taken from
the session's start are important when the entire session is considered.
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Grieg, acting a bit like the devil he proclaimed himself to be, wreaked
havoc at his adult child's house and said insulting things to the spouse. He
also mentions needy children that he felt he should help, ones that are
starving. While this can be taken in the abstract in terms of children a
world away, in the concrete, his adult children needed him but they might
as well have been half a world away given his inability to help them.
Finally, there was a quality of hopelessness and a sense of a destiny to be
humiliated should he try to help those children. Perhaps he felt as likely to
connect to his own children as to become king. But how was Grieg able to
move from his delusional idea of being the devil and of starving children
innumerable miles away to a recognizable story of loss and grief, a coherent
narrative allowing for empathic connection, a palpable sense of relief, and
implications for future more adaptive actions? It seems possible, again
through the lens of phenomenology, the primary action was the therapist
offering the scaffold of "you", allowing Greig to try it repeatedly. Indeed,
Grieg tried and lost it, and the therapist tossed it again. Thus, first the
therapist offered a common-sense interpretation of the experience Greig
related, and then the therapist and he continued their discussion as
partners in an intersubjective space. Grieg and the therapist began to
acknowledge one another's views, and Grieg began to acknowledge the
feelings of others and remarkably, to assume an intentional stance over his
own experiences. Grieg noticed that he said odd things spurred on by
jealously. He was able to experience himself in "the you" that was jointly
seen by himself and his therapist. Additionally, Greig experienced himself
as an agent worthy of empathy, who might act differently in the future.

FOUR ELEMENTS OF A PHENOMENOLOGICALLY INFORMED

PSYCHOTHERAPY AND ACCOMPANYING VIGNETTES
In describing a single session, we have sought to provide an example of
how the insights of phenomenology could be applied to understand the
processes of psychotherapy that is, to assist persons with schizophrenia
move toward recovery. Following this view, what would the general
principles of this psychotherapy be, and how might they differ from other
approaches?
Based on this example and examination of our own psychotherapeutic
work, we suggest that the specificity of the insights of phenomenology lie
in how they seek to relate to, or "understand" the patient's symptoms and
abnormal experiences. After reviewing our own clinical work, we believe
there are at least four ways, distinguishable from other approaches, in
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which therapists may understand or relate to patients. We have labelled

these:
(I) highlighting disturbances of intersubjectivity,
(II) aiming at achieving a shared partnership,
(III) focussing on the here-and-now, you-and-I relationship, and
(IV) pointing to shared meaningfulness.
In what follows below we describe and illustrate these principles, and we
clarify how they suggest a vantage point which differs from others.
I. HIGHLIGHTING DISTURBANCES OF INTERSUBJECTIVITY
First, a psychotherapy based on the second-person perspective sees
difficulties with intersubjectivity as a core feature of schizophrenia—not an
epiphenomenon. Cognitive approaches, by contrast, tend to see positive
(e.g. delusions or hallucinations) and negative symptoms (e.g apathy) as
examples of inaccurate or dysfunctional perceptions and thinking, which
lead to misunderstanding separate persons and withdrawal (Fowler, Ga-
rety, & Kuipers, 1995). Viewed from a cognitive approach, persons with
schizophrenia, cannot connect because they have idiosyncratic cognitions
about reality. Social dysfunctions are consequences of dysfunctional cog-
nitions. Therapy, therefore, focuses on dysfunctional cognitions (e.g. de-
lusions), and therapists assist patients to examine evidence supporting (or
not supporting) delusions to help revise beliefs. Our views stand in even
starker contrast to psychoanalytic views, which sees psychosis as a problem
beginning with internal conflict and one located within one's mind. For
instance, Lucas (2003) asserted that in psychosis "the mind relieve(s) itself
of emotional pain" through positive symptoms that secondarily distance
one from the world (p. 6). Although our approach has several points
congruent with some psychoanalytic theories (e.g. Fonagy & Target, 1997)
—especially those influenced by phenomenology (Atwood, Orange &
Stolorow, 2002; Stern, 2004)—these theories are rarely applied to the
treatment of persons with schizophrenia. Thus, where cognitive views
target beliefs, and some psychoanalytic views target conflict, we focus on
the promotion of the experience of self in the second person as a necessary
first step to change. In contrast to cognitive and psychoanalytic views, our
approach highlights the inability to share a view of oneself in the second
person with others as a major root of vulnerability to schizophrenia
(Stanghellini & Ballerini, 2002). Persons with schizophrenia lack easy
access to the second person, a position necessary for intersubjectivity, and
they lack, secondarily, the ability to process discomfort. In this sense,
schizophrenia can be construed as a disorder of common sense (Blanken-

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burg, 1971), that is, a disorder of the ability to accurately perceive of the
dispositions and intentions of other individuals. To a certain degree, this
view overlaps with some approaches that see schizophrenia as a disorder of
social cognition (Penn, Corrigan, Bentall, Racenstein & Newman, 1997).
This is not to deny how disabling delusions and hallucinations can be.
We do, though, dispute that there is linear, unidirectional pathogenesis
from positive symptoms to social dysfunctions. Excruciating pain, feelings
of strangeness and alienation, experiences of derealization, and unusual
thoughts may be viewed as in part proceeding from the inability to enter
into intersubjectivity. We also hold out the possibility that, with a greater
ability to participate in the world intersubjectively, those symptoms maybe
easier to manage. In other words, without the ability to participate in the
worlds of others those symptoms may become even more un-understand-
able and consequently unmanageable.
Vignette I
Ornella is a 30-year old woman who often complains about pervasive
feelings of depersonalization and derealization: "I cannot feel my being
anymore. If I cannot feel myself, I cannot have control over an action. If
I cannot feel myself, I cannot feel. I cross the street, and I don't realize it,
and I must cross it again. I wash myself, and I am not aware of it." Lack
of first-person perspective over her experiences engenders sensory-motor
disintegration ("If I cannot feel myself, I cannot have control over an
action") and the loss of the capacity to have sensations ("I cannot feel"').
These abnormal bodily sensations and lack of presence convey a third-
person perspective of herself. There is no internal sense of self-awareness,
only an external one: "I cannot say T'"—she says—"in relation to myself,
but only in relation to the others." This shows that lack of self-awareness
is alleviated only by the presence of meaningful others—evidence of the
mutual constraints between a sense of personal and intersubjective self.
Empathic attunement, especially during therapeutic sessions, mitigated her
feelings of depersonalization and derealization: "When I am here talking
with you all this does not happen."
n . AIMING AT ACHIEVING A SHARED PARTNERSHIP
We assert, secondly, that the primary action of a phenomenologically
informed therapy is to achieve a shared partnership in the second person
with the patient. We argue that helping persons with schizophrenia correct
dysfunctional cognitions, which is proposed as the primary action of
cognitive therapies, or understanding the history and vicissitudes of inner
conflicts or complexes, as is proposed by some psychodynamic therapies,
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keeps the therapist and patient in the third-person perspective. The issue
of the effectiveness of psychoanalytic psychotherapies for schizophrenia is
certainly controversial (Lucas, 2003; Michels, 2003). Recent psychoanalytic
approaches de-emphasise the role of interpretation and place greater
emphasis on the therapeutic partnership as the main therapeutic factor
(Frank & Gunderson, 1990; McGlashan & Nayfack, 1988). That is, the
process of therapeutic change is embedded in "moments of meeting," the
intersubjective matrix (Stern, 2004). Research suggested that, especially
with people with schizophrenia, interpretation should be made only after
the therapeutic alliance is consolidated (American Psychiatric Association,
Diagnostic and statistical manual of mental disorders [4th ed., 1994).
Nevertheless, much psychoanalytic writing still suggests patients difficul-
ties are best understood by focusing on specific thoughts and/or conflicts
as divined by the therapist. We suggest to the contrary that the therapist
who sees the patient through the lenses of a metapsychology overwrites the
patient's experiences and meanings instead of exploring them in an
interpersonal (you and I) setting.
To illustrate, Lucas (2003) suggests that in cases of chronic schizophre-
nia disorders, such as Grieg's, the psychoanalytic therapist's job is to
"think and care for" the patient. Werbart and Levander (2005) similarly
suggest that the goal of psychoanalytic treatment for schizophrenia is the
creation of "an internal space for the metabolizing incomprehensible
experiences" (p. 125). Here we propose the patient is seen as prey to
uncanny happenings taking place inside her/himself that the therapist
should help to clarify so that connection with others will be possible. The
danger here is that the psychotherapeutic process aims the normalization
of the patient's experiences by creating a narrative that fulfils the con-
straints of the therapist's metapsychological knowledge. By contrast, the
aim of the dialogic process as illuminated by phenomenology is to enhance
the patient's acknowledgement of the presence of the other as another
person, a condition necessary for re-establishing a first person perspective
of one's self—the re-appropriation of one's own experiences. The space in
which the phenomenologically informed psychotherapy takes place is not
"internal", but intersubjective. The process takes place in the open, public,
liminal space that lies between the therapist and the patient. The rapport
between them is one of co-presence. In this context, understanding means
negotiating a cross-subjective construct connecting two different horizons
of meanings. In contrast to cognitive approaches, we are not interested in
two separate parties examining cognitions as objective data (e.g. Garety &
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Freeman, 1999) but as two parties co-constructing a sense of the patient's

anguish and abilities in the second person.
Vignette II
Carter is a psychotherapy patient with a delusion of exceptional power
and status. He asserts this, and offers implausible proofs. Hearing each
explanation, the therapist slowly comes to think that this delusion is often
an explanation for feeling rejected by others, which is itself an interpre-
tation of the feeling that he radically does not "fit in" with others. Carter
reasons that because he possesses extreme social status, others are jealous
of him and reject him. Therefore, he is utterly alone in the world. Yet
Carter cannot fathom how implausible his explanations are to the therapist
and becomes enraged with him.
Carter takes the therapist's confusion as proof the therapist is indiffer-
ent to or jealous of him. When the therapist explores and challenges
Carter, he admits that because he does not believe everything he is told,
that the therapist might not believe everything he. Carter, says and might
have a view of him different from the desired one. This exchange leads to
the development of a shared second-person view of Carter as a man
overwhelmed by his beliefs. This is not to say these beliefs are accurate or
inaccurate, merely that these beliefs that flood Carter's awareness beyond
his control. With this. Carter abandons his delusions briefly but then
discovers these beliefs have an additional power. He asks if the therapist
would "want to give up believing" that he had exceptional status. The
therapist replies that if he had such a belief he might be tempted to keep
it because it might shield him from feeling shame if he treated others
poorly. The patient finds this thought helpful and comforting and the
delusions fade further.
III. FOCUSSING ON THE HERE-AND-NOW, YOU-AND-I RELATIONSHIP
We, thirdly, assert that a psychotherapy informed by phenomenology
focuses on the here and now of the you-and-I relationship. We are much
more concerned with engagement in the "real" world as opposed to inner
life or past experiences, though we certainly see that patients can be
conflicted about many issues. Our view, however, emphasizes that their
conflicts and complexes may fester and be terribly disabling because of
difficulties participating in the world in the second person. Thus, though
psychotherapy may help persons with schizophrenia resolve conflicts, it is
necessary for the patient first to re-establish a degree of intersubjectivity.
Intersubjectivity is seen as the problem addressed by psychotherapy, not
something that improves when other problems are addressed and solved.
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The aim of the therapeutic process is to help the person with schizophrenia
re-establish the 'intentional arc' that connects him or her with the present
context. The intentional arc (Merleau-Ponty, 1945) brings the self to the
present situation, bridging at any moment, the intentional object "I am
about out there" with the background of sensations and activities that
reside in my body. Thanks to this "arc" the body's input keeps the person
continuously (and pre-reflexively) aware that it is I who is having the
experience of the intentional object (Stern, 2000). This may be the
movement I am performing, the perception I am having, or the behaviour
of the other person, which I am about to understand. The intentional arc
is the preconscious, biologically built-in root of the first-person perspec-
tive, i.e. of the sense of ownership and agency (Damasio, 1999).
We propose that in persons with schizophrenia this arc is damaged, and
self and world fall apart. Emotions in the "I-You" relationship that
normally situate the person, for example, "My heart is beating fast because
I am happy to see you again" may emerge as abnormal and uncanny bodily
sensations. In this context, even "my heart is beating" may become an
incomprehensible and perplexing event, to be explained through delu-
sional third-person narratives. For people with schizophrenia the imme-
diacy of one's sense of self and of other as connected to present situations
may be dissolved. Psychotherapy may serve as a "dialogical prosthesis" to
help re-establish the lost connection between bodily feelings (emotions)
and interpersonal situations. The task of the therapist is promoting the
construction of micro-narratives focussed on real world situations (espe-
cially here-and-now, You-and-I situations). If the basic disorder in schizo-
phrenia is the failure to establish implicitly a prereflexive sense of a
situated self, then the psychotherapeutic process needs to help reconstruct
(or construct) explicitly this through developing a verbal, narrative-based
sense of the self.
Vignette III
Piera is 38-year-old woman. She reports that since adolescence she has
been shocked by inexplicable "strange bodily sensations." During one
therapy session, Piera sees a connection between these bodily sensations
and the "orgasms" she has when "telepathically" in contact with her
therapist. She first wants the therapist to confirm that heart the very
moment of her "orgasm" he is thinking of her. But she reconsiders this
telepathic connection when she fears that her death "premonitions" about
him may cause him harm. She asks him to be reassured that no such things
like telepathy are possible at all. A micro-narrative linking her uncanny
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bodily sensations to arousal in the presence (or thought) of the therapist is

patiently established. At this moment Piera realizes that the strange bodUy
sensations affecting her are emotions taking place in the "I-You" relation-
ship. She also realizes that what she still calls orgasms are strong sensations
of emotional arousal. She recovers a sense of being situated in the world
and her delusion of being telepathically in contact with her therapist
gradually disappears.
IV. POINTING TO SHARED MEANINGFULNESS
Finally, the second-person approach as a method searches for shared
narratives as a means of co-constructing stories that need to have internal
coherence and external coherence (Stanghellini, 2004, Stanghellini 2007).
Since clinical narratives are the patient's attempt to arrive at meaningful
understanding, it is essential to fulfil internal coherence or consistency. As
patterns of meanings emerge during the therapeutic process, clinical
narratives are points of intersection of two subjectivities (Atwood &
Stolorow, 1984; Lysaker et al., in press). The degree to which each
narrative is grounded in interpersonal constraints is called "external
coherence." External narrative coherence is twofold. First, negotiation is
required between the patient's way of narrating the experiences and story
as [the patient believes] the therapist understands it. Through this process
a liminal, it establishes a dual mode of understanding, revealing differences
as well as points of intersection. Second, there is a need to confront the
patient's narrative with the societal horizon of meanings (Gadamer, 1986).
Through this process, which sees the interviewer as a mediator, deviations
from common sense or standard knowledge are sorted by theme and
examined critically. Thus, the therapist is not merely nondirective, echoing
back what he or she hears. The benchmark of this intersubjective process
is its capacity to enhance the patient's ability to acknowledge the other's
point of view, and by doing so, improve the capacity to sense experiences
as his or her own, and reflect upon them, and take an intentional stance
over them. Following this, the patient may acknowledge feelings and
processes in same way as a person who does not experience psychosis.
Vignette IV
Glass is a psychotherapy patient, who, in the past, while acutely
agitated and deluded, performed an act in front of others that was, and still
is, deeply embarrassing for him. He has no story or explanation for
behaviour that allows him to feel understood by the others in an empathic
manner. He concludes that he is "crazy" and that others should not trust
him. His only option is silence, and he concludes this, and other embar-
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AMERICAN JOURNAL OF PSYCHOTHERAPY

rassing feelings, can be understood only by psychiatrists. When the

therapist challenges Glass to consider his hypercritical stance. Glass
becomes mistrustful, fearing humiliation. The therapist presses the matter,
and it is Glass who realises that there may be a way to understand this
hypercritical self-evaluation. In the weeks before the embarrassing event.
Glass felt a growing frustration and distance from others, he also felt rage
and a sense of self-deprecation. As the therapist and Glass examined his
embarrassing behaviour in the second person viewpoint, they agree that
Glass was very much in control when he behaved as he did. They conclude
that (i) though Glass regrets performing that embarrassing act, (ii) the act
allowed him to express to others something important to him. He behaved
as he did because of overwhelming emotions and a sense of distance from
others.

CONCLUSIONS AND FUTURE WORK

Through the lens of phenomenological studies of self-experience in
schizophrenia, we have reviewed how that the second-person, "I-You"
perspective on the social world is compromised in schizophrenia, and how
the kind of social dysfunction in schizophrenia is a core feature of this
condition, not an epiphenomenon of positive or negative symptoms. We
propose that the primary action of therapy is to achieve a shared partner-
ship, that is, a sense of striving for the same goal, which initially may
remain implicit but which emerges in explicit statements during the
psychotherapeutic process. We assume that this achievement can be made
by encouraging the patient to tell his or her story, accepting as a necessity
that s/he may sometimes not directly talk about her- or himself, but
indirectly and metaphorically address her/his own experiences, teUing
stories in the third person. We suggest that the crucial step of the
psychotherapeutic process is offering the "You" or second-person per-
spective. If the therapist patiently keeps offering a second-person view, the
patient may evolve a first-person account, assuming an intentional stance
over experiences. This may help the patient start to recover a sense of
subjectivity (first-person perspective over one's experiences and actions)
and intersubjectivity (second-person perspective over others).
We have also highlighted two basic methodological aspects: one is
avoidance of standard interpretations based on metapsychology since these
may consolidate a third-person approach and perception of the self and
discourage the process of appropriating a life history. The other focuses on
the here-and-now of the You-and-I relationship, rather than on past
conflict or complexes and encourages expression of present feelings and
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Intersubjectivity in the Psychotherapy of Schizophrenia

experiences to help to dialogically re-establish disrupted immediate con-

nectedness between the self and the present situation (intentional arc). The
use of micro-narratives may enhance the abilities of persons with schizo-
phrenia to restore lost unity between bodily feelings (emotions) and
interpersonal situations, and hence recover a core sense of self and of self
with the other.
Thus, the lens of phenomenology seems to offer much in the way of
new and innovative ways to view psychotherapy for persons with schizo-
phrenia. This paper represents only a beginning of the research necessary
to explain the progress we see in individual sessions, and it suggests
principles that may further the development of the psychotherapy of
schizophrenia. Future work is necessary to develop reliable and valid
means to assess each step of the therapeutic process and the changes in
person's experience of self in the first and second person. Especially
important is the issue of how to assess a person's self-experience and
experience of self-in-relation-to-others in a manner that does not objectify
it. Such methods are necessary to take the next step and track 1) patient-
therapist negotiation and (2) critical integration between the patient and
the "societal horizon" of meanings and values that are attached to the
patient's abnormal behaviours, experiences, and beliefs. We hope that in
a not distant future, using methods currently under development, we wiU
be able to assesses a patient's acknowledgement of the other's the point of
view, and not merely the "normalization" of the patient's experiences and
beliefs (Lysaker, et al, 2005; Lysaker, Clements, Placak, Hallberg, Knips-
chure, & Wright, 2002). Such work, if pursued systematically, may ulti-
mately lead to more systematic study of the patient's capacity to take an
intentional stance over his or her experiences and beliefs and may become
the yardstick of a phenomenologically, intersubjectively based psychother-
apy of persons with schizophrenia.

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