Psychotherapy Research, 2018

Vol. 28, No. 3, 457–469, https://doi.org/10.1080/10503307.2016.1216624

EMPIRICAL PAPER

Interactional synchrony and negative symptoms: An outcome study of

body-oriented psychotherapy for schizophrenia

LAURA GALBUSERA1, MICHAEL T. FINN2 , & THOMAS FUCHS1

1
Clinic for General Psychiatry, University of Heidelberg, Heidelberg, Germany & 2Department of Psychology, University of
Tennessee, Knoxville, TN, USA
(Received 16 November 2015; revised 14 July 2016; accepted 16 July 2016)

Abstract
Objective: We sought to assess the efficacy of a manualized body-oriented psychotherapy (BPT) intervention for
schizophrenia, by focusing on improvement of negative symptoms and on changes in interactional synchrony. We also
explored aspects of a phenomenological theory of schizophrenia, which states that negative symptoms should be
understood within an encompassing disturbance of subjectivity and intersubjectivity. Method: Sixteen persons with
schizophrenia participated in 10 weeks of BPT. General psychiatric symptomatology and negative symptoms were assessed
before and after therapy. Interactional synchrony was assessed via cross-correlations of movements between patient and
interviewer in interviews conducted before and after therapy. Results: Psychiatric symptomatology and negative
symptoms significantly improved with a medium effect size. We also demonstrated a significant increase in interactional
synchrony with a strong effect size. Post hoc analyses showed a significant increase only with open-ended interviews
conducted by the same interviewer. Furthermore, we explored the correlation between negative symptoms and
interactional synchrony, finding a large inverse relationship. Conclusions: BPT for schizophrenia may effectively reduce
patients’ negative symptoms and psychiatric symptomatology. Moreover, it may yield some recovery of pre-reflective social
relations. Further evidence of the specific relation between negative symptoms and interactional synchrony would support
a phenomenologically informed holistic view of schizophrenia.

Keywords: outcome research; philosophical/theoretical issues in therapy research; psychosis/severe mental illness; body-
oriented psychotherapy; interactional synchrony

Across different fields of research on schizophrenia,
one theme of this severe condition recurs: an inter-
subjective disturbance. Clinical reports, phenomeno-
logical explorations, experimental, and even
neurological studies explored the intersubjective
dimension in schizophrenia. The disturbance has
been referred to as a disconnection from the shared
intersubjective world (Blankenburg, 1971; Min-
kowski, 1970), a disturbance of the “in between”
(Kimura, 1982), a disruption manifested in the trans-
ference relation (Karon & Vandenbos, 1977) or an
intersubjective existential struggle (Galbusera &
Kyselo, 2016; Kyselo, 2015). A common element
across these concepts is that this odd feeling of dis-
connection, of missing flow in the face-to-face
encounter is manifest first and foremost at the
pre-reflective level of experience. That is, one can
implicitly sense that something is different in the
face-to-face interaction with patients, although it is
difficult to name. Notably, such uncanny feelings in
the intersubjective encounter even became an intui-
tive basis for diagnosing schizophrenia in what
Rümke (1941) introduced as the “praecox feeling”
(see also Grube, 2006; Varga, 2013).
Although this pre-reflective intersubjective
dimension seems to play a crucial role in schizo-
phrenia, the importance of this phenomenon is
largely ignored in current diagnostic criteria. A
typical, DSM-informed view of schizophrenia
encapsulates the disorder mainly into behavioral
manifestations (symptoms), leading to an underesti-
mation of the role that first-personal and second-

Correspondence concerning this article should be addressed to Laura Galbusera, Clinic for General Psychiatry, University of Heidelberg,
Vossstrasse 2, Heidelberg 69115, Germany. Email: 8laura.galbusera@gmail.com

© 2016 Society for Psychotherapy Research

458 L. Galbusera et al.
personal experience can play in the understanding of
schizophrenia (Parnas, Sass, & Zahavi, 2013). In
contrast to the mainstream approach, in this paper,
we focus on the embodied intersubjective disturb-
ance in schizophrenia instead of only focusing on
symptoms. We do this by adopting a phenomenolo-
gical perspective. Then, we apply this perspective to
psychotherapy research.
In the present paper, we look at embodied inter-
subjectivity for assessing the efficacy of a body-
oriented psychotherapy (BPT) intervention for
schizophrenia. We operationalize and empirically
investigate embodied intersubjective processes by
measuring patients’ interactional bodily synchrony.
In what follows, we set the theoretical background
for the hypotheses and methodology of this study.
A Phenomenological Perspective on Negative
Symptoms
A mainstream approach to understanding schizo-
phrenia holds an essential difference in positive
and negative symptoms. These are considered as
independent entities: the first indicate the appear-
ance of clinical manifestations such as hallucinations
and delusions and the second refer to a lack of
normal functions (e.g. anhedonia, apathy). Positive
symptoms are traditionally the main target of treat-
ments, such as pharmacological options, whereas
the negative symptoms still remain a persistent and
pervasive problem in treatment over the long term
(Milev, Ho, Arndt, & Andreasen, 2005). In con-
trast, contemporary phenomenological psychiatry
emphasizes the importance of considering patients’
experience first and foremost as an interconnected
meaningful whole (Parnas et al., 2013). These foun-
dations lead to the conceptualization of schizo-
phrenia as a disorder of the most basic sense of self
(Parnas & Sass, 2001; Sass & Parnas, 2003).
Parnas and Sass (2001) and Sass and Parnas
(2003) describe the core feature of the whole of
schizophrenia experience in terms of an ipseity dis-
order, that is a diminished sense of being a first-
person embodied subject of awareness and action.
Such a pervasive disturbance of subjectivity is, at
the same time, a disorder of “self-with-others”
(Fuchs, 2013). Indeed, a diminished self-presence
(also referred to as an ipseity disturbance) is
related to a pre-reflective disconnection from the
social environment or, in Minkowski’s (1970)
words, a diminished “me-here-now-presence.”
The loosening of the implicit and immediate
relation to the world and others, also known in the
phenomenological literature as schizophrenic
autism, has been described as a crucial characteristic
of the schizophrenic experience (Stanghellini & Bal-
lerini, 2002, 2004).
A shift from the realist and positivist epistemology
informing the DSM to a phenomenological view of
psychopathology has already proven useful for a
better understanding of schizophrenia, leading to
more reliable diagnoses. Indeed, the exploration of
the pre-reflective dimension of self-experience and
intersubjectivity has highlighted characteristic phe-
nomenological features that have been shown to be
crucial for an accurate differential diagnosis of schizo-
phrenia (Haug et al., 2012; Nordgaard, Revsbech,
Saebye, & Parnas, 2012; Nordgaard, Sass, &
Parnas, 2012). This pre-reflective and intersubjective
disturbance shares much in common with the tra-
ditional understanding of negative symptoms. Con-
sider, for instance, behaviors such as affective
flattening, anhedonia, asociality, apathy, and social
inattentiveness: they all point to a lack of implicit
and bodily spontaneous expression and to a discon-
nection at the pre-reflective intersubjective level (see
Van Duppen, 2015 for an in-depth analysis along
these lines). Looking at negative symptoms through
the lens of phenomenology, it appears that these
cannot be conceived as “removed” features of the dis-
order, pointing to a mere lack of normal functions.
On the contrary, they have been shown to be comp-
lementary and integrated aspects of a qualitative
transformation in the whole structure of experience,
concerning subjectivity and intersubjectivity (Parnas
& Sass, 2001; Sass & Parnas, 2003). Given the impor-
tant role negative symptoms have for the prognosis
and long-term course of the disorder, we believe
that a phenomenological view on negative symptoms
might not only contribute to psychodiagnostics but
also to psychotherapy research.
In order to empirically investigate the intersubjec-
tive disturbance in schizophrenia, in what follows,
we narrow down our focus to a core specific aspect:
the temporal dimension of synchronization and attu-
nement. We thereby operationalize the broader
notion of embodied intersubjectivity into a more
specific measurable construct.
Schizophrenia as Intersubjective
Desynchronization
Minkowski (1970) has described the specific tem-
poral dimension of the pre-reflective intersubjective
disconnection in schizophrenia as a disturbance in
lived time: an experiential desynchronization from
the environmental contingencies and a diminishment
of vital and intuitive attunement in the relation with
others. More recently, Fuchs (2007) has described
the lacking implicit “timing” in the interaction

(including aspects such as synchronization and
rhythm) as a crucial aspect of the experienced sense
of disconnection in schizophrenia (Fuchs, 2001,
2005, 2010). He called it a disturbance of intersub-
jective temporality, which implies a sense of desyn-
chronization from others (Fuchs, 2010).
In this paper, we claim that the phenomenological
sense of detachment in the intersubjective encounter
finds its phenomenal counterpart in the desynchroni-
zation of movement at the bodily level. This link
allows the operationalization of a phenomenological
construct into an empirical and observable one.
The concept of participatory sense-making1, as it
was elaborated by Fuchs and De Jaegher (2009), pro-
vides a theoretical basis for this claim.
With the notion of participatory sense-making,
Fuchs and De Jaegher (2009) integrated a phenom-
enological description of intersubjectivity with its be-
havioral counterpart. On the one hand, they describe
the pre-reflective process of intersubjective under-
standing and sense-making as the phenomenological
experience of “mutual incorporation”2: a co-pres-
ence and reciprocal interaction of lived bodies that
through action and perception intertwine in mean-
ingful and immediate ways. On the other hand, pre-
reflective intersubjective understanding is considered
to be embodied and enactive: as two persons coordi-
nate in making meaning together, they also intertwine
their movement (De Jaegher & Di Paolo, 2007;
Fuchs & De Jaegher, 2009). Subjective intercorporeal
experience and dynamics of movement coordination
are two sides of the same coin. In accordance with
this notion, the experience of pre-reflective intersub-
jective detachment typical of schizophrenia might be
similarly conceived as being related to disrupted
dynamics of movement coordination.
Bernieri and Rosenthal (1991) distinguished two
different aspects of movement coordination: behavior
matching and interactional synchrony. Whereas the
first indicates qualitative and static behavioral fea-
tures of the individuals such as postures, mannerisms
or facial displays, the latter refers to the temporal
dynamics of coordination, which are dependent
upon both each individual’s intentions and the
dyadic system.3 Interactional synchrony is thus a
quantitative measure of the intersubjective temporal
modulation of bodily movement, which indicates
different degrees of temporal relatedness. This
measure grasps the phenomenon of movement
coordination as it is implied in the notion of participa-
tory sense-making4: the bodily “timing” of the inter-
subjective coupling, which assays different degrees of
pre-reflective engagement (mutual incorporation) in
intercorporeal encounters. According to these con-
siderations, the disorder of intersubjective tempor-
ality in schizophrenia might be also coherently
Psychotherapy Research 459
viewed at the bodily level in terms of a disruption of
interactional synchrony. Although the empirical
phenomenon of bodily synchrony does not encom-
pass the whole complexity of the intersubjective dis-
turbance at stake, we believe that it might be validly
conceived as a behavioral manifestation of it.
Interactional Synchrony and Psychotherapy
Research
Since the first empirical investigations, interactional
synchrony was considered as expressing connected-
ness between persons interacting (McDowall,
1978). Research findings over the last decades have
shown and confirmed that the temporal intertwine-
ment of movement has its correlate in the reciprocal
orientation toward the other’s intentions and
motives (e.g., Bernieri, Reznick, & Rosenthal, 1988;
Condon, 1980; Oullier, de Guzman, Lagarde, &
Kelso, 2008). As Kendon (1970) has put it: “to
move with another is to show that one is ‘with’ him
in one’s attentions and expectancies” (p. 124).
Taking a further step, more recent studies on interac-
tional synchrony have associated it to rapport, feeling
of emotional closeness, compassion, and positive
relationship (e.g., Julien, Brault, Chartrand, &
Begin, 2000; Koss & Rosenthal, 1997; Miles, Nind,
& Macrae, 2009; Tickle-Degnen & Rosenthal,
1990; Tschacher, Rees, & Ramseyer, 2014; Valde-
solo & De Steno, 2011). Coherently with these
results, few studies on psychotherapy have shown
that interactional synchrony is directly correlated
with the quality of the therapeutic relationship and
with the outcome of therapy (Darwiche et al., 2008;
Nagaoka & Komori, 2008; Ramseyer & Tschacher,
2011, 2014, 2016).
Nonverbal communication in psychotherapy has
been widely investigated, based on the awareness
that nonverbal behavior plays a decisive role in
relationship formation and therapeutic outcome
(e.g., Hall, Harrigan, & Rosenthal, 1995). Yet, the
focus has been mainly on the quality of individual
behavior (as opposed to dyadic dynamics) and on
the role of mimicry and behavior matching (as
opposed to interactional synchrony) (Ramseyer &
Tschacher, 2011). Only recently, the interest for
the phenomenon of interactional synchrony has
began to grow and the proper methodologies for
studying interactional movement dynamics have
been developed (Koole & Tschacher, 2016). One
major step in this direction has been the work by
Ramseyer and Tschacher (2011), who stressed the
importance of exploring the nonverbal dynamics of
interaction occurring at the system level of the thera-
pist–patient dyad, that is, interactional synchrony.
460 L. Galbusera et al.

In doing so, they have developed a computational Current Study

method for recording and analyzing the general
In this study, we continue the line of research on the
movement dynamics of a dyad: Motion Energy
efficacy of BPT by first addressing changes in nega-
Analysis (MEA). This methodological instrument
tive symptoms and standard psychiatric measures.
has opened the possibility of measuring interactional
Additionally, we consider empirical changes in
synchrony in the dynamic coordination of move-
patients’ embodied intersubjective relations.
ment of the dyad through the empirical analysis of
Indeed, although dimensions of subjectivity and
digital video.
self-disorders have already been addressed in BPT
outcome studies (Röhricht et al., 2009), the dimen-
sion of embodied intersubjectivity remains unex-
BPT for Schizophrenia plored. We believe that looking at patients’
embodied interactions is of crucial importance for
Based on the conclusions of phenomenological psy-
two reasons. First, according to a phenomenological
chiatry, therapeutic interventions have been developed
approach, a disruption at the level of embodied inter-
that address first and foremost the implicit and pre-
subjectivity is at the core of the schizophrenic disturb-
reflective level of experience. Embodied intersubjec-
ance. Second, the specific embodied quality of BPT
tivity and pre-reflective self-awareness are the target
targets embodied intersubjectivity as a crucial
dimensions of BPT, where implicit experiences and
medium for therapeutic change. It is thus of clinical
nonverbal interactions play a central role for the
relevance to explore whether changes within this
process of therapeutic change (Röhricht, 2000,
dimension are observable as a result of the BPT inter-
2009). BPT is the overarching term for such tech-
vention. Due to the novelty of this approach in the
niques that span across a heterogeneity of settings
assessment of therapy outcome, the present study is
and targets (see Röhricht, 2009 for a review). Predo-
still of pilot and exploratory nature.
minantly nonverbal interventions in psychotherapy
By focusing on the temporal dimension of the inter-
have been developed especially for body-related psy-
subjective disturbance in schizophrenia, we have oper-
chopathologies (somatoform disorders, medically
ationalized the notion of embodied intersubjectivity
unexplained symptoms, posttraumatic stress dis-
into the empirical construct of interactional syn-
orders, eating disorders, and schizophrenia) and for
chrony. Following Ramseyer and Tschacher (2011),
target patients who do not respond to talk therapy,
in this study, we measure interactional synchrony by
or where speech may not be the most suitable thera-
means of the MEA method. Two main hypotheses
peutic medium (Galbusera & Fuchs, 2013; Röhricht,
were formulated for this study. First, we hypothesized
2009). In this paper, we focus on an intervention for
that we would replicate previous outcome studies on
schizophrenia, manualized by Röhricht (2010) (see
BPT for schizophrenia by confirming that improve-
also Röhricht & Priebe, 2006).
ment in negative symptoms and general psychiatric
Although this BPT intervention for schizophrenia
symptomatology measures could be observed after
has been specifically created for targeting negative
the BPT intervention. Second, we hypothesized that
symptoms (Röhricht, 2010; see also Röhricht &
the BPT intervention has an effect on patients’ embo-
Priebe, 2006), a theoretical grounding in the phe-
died interactions: in contrast to a pre-reflective discon-
nomenological tradition has allowed an understand-
nection from others, dynamics of interactional
ing of negative symptomatology within a holistic
synchrony may be reestablished through BPT. In
perspective of schizophrenia as an experiential self-
order to examine this hypothesis, we analyzed levels
disorder (Röhricht, 2000; Röhricht, Papadopoulos,
of interactional synchrony before and after treatment
Suzuki, & Priebe, 2009; Röhricht & Priebe, 2004;
in a separate setting (interviews).
Scharfetter, 1999). Practice-based clinical evidence
Finally, we explored the correlation between inter-
and a few empirical trials have shown the efficacy of
actional synchrony and negative symptoms, with the
BPT in reducing negative symptoms (Röhricht &
aim of understanding whether these symptoms
Priebe, 2006; Röhricht, Papadopoulos, Holden,
might indeed be related to a core disturbance of
Clarke, & Priebe, 2011; Priebe et al., 2013) and
intersubjectivity.
these results have been also linked to dimensions of
self-disorders (Scharfetter’s ego-pathology scores;
Scharfetter, 1981, 1999) showing a link between the
two (Röhricht et al., 2009). By this linkage, negative Method
symptoms have been shown to be related to the
Participants
core disturbances of subjectivity in schizophrenia,
instead of merely being conceived as “removed” fea- Originally, 25 patients were recruited for the study, 9
tures of the disorder. of them dropped out5 and 16 patients were therefore

included in the study (N = 16; 13 male, 3 female;
Mean age = 43, SD = 12.7). Inclusion criteria were
a diagnosis of schizophrenia spectrum disorders
ICD10 F20-F29 (with exclusion of F23—acute and
transient psychotic disorder). Exclusion criteria
were any presence of current substance-induced psy-
chosis, current participation in inpatient treatment,
and a diagnosis of mental disability or an organic
brain syndrome. Fifteen patients were diagnosed
with paranoid schizophrenia6 (F20.0; ICD-10) and
one with schizoaffective disorder (F25.9; ICD-10).
Diagnoses were made by the treating psychiatrists
according to the ICD-10. Fifteen patients were
treated in outpatient setting and one in outpatient
and day hospital setting. All patients were Caucasian.
Nationality and mother tongue were German for all
patients apart from one, whose nationality and
mother tongue were English.
Procedure and Setting
Patients were recruited from three sites: the psychia-
tric University Clinic in Heidelberg (eight patients),
the psychiatric center Nordbaden in Wiesloch
(three patients), Germany, and the psychiatric outpa-
tient institute in Mosbach (five patients), Germany.
The study procedures were approved at all sites and
all patients signed informed consent documents
before participating. All data were treated anon-
ymously and confidentially. The BPT intervention
was implemented across the three psychiatric
centers in group settings and unfolded over a period
of 10 weeks with bi-weekly 90-minute sessions.7
The intervention was led according to the manual
guidelines (Röhricht, 2010) by one trained body-
oriented psychotherapist and two co-therapists
trained in clinical psychology. Body-oriented psy-
chotherapists were directly trained by the authors of
the treatment manual.
All patients took part in at least 80% of the treatment
program. During the intervention period, patients did
not take part in other therapy offers on a regular
basis.8 All patients received pharmacological therapy
(neuroleptic medication) which did not change
during the BPT intervention period. Symptom assess-
ments were implemented with all patients by trained
research assistants before and after therapy. For the
assessment of synchrony, additional qualitative semi-
structured interviews were implemented by L.G.
(first author), trained clinical psychologist, before and
after BPT. These interviews were implemented
according to phenomenologically oriented interview
methodology (e.g., Nordgaard et al., 2012).
In order to measure changes before and after
therapy, interactional synchrony was measured for
Psychotherapy Research 461
the qualitative interview before therapy (the prether-
apy interview), for the qualitative interview after
therapy (the posttherapy interview), and for the stan-
dardized symptom evaluation after therapy (the
symptom evaluation). The posttherapy interview
maintained the same interviewer of the pretherapy
interview and the same interviewing style; this
allowed a reduction of contextual and interpersonal
variability. The symptom evaluations were conducted
by interviewers who were unknown to the patients, in
order to rule out the effect of familiarization (with the
same interviewer) on synchrony measures and there-
fore to test the generalizability of the synchrony
changes. To reduce the difference of interactional
context between the qualitative interviews and the
symptom evaluations, interviewers conducting the
symptom evaluation were instructed to keep a loose
conversational style (similar to the qualitative inter-
views) during the first 15 minutes. All interviews
were videotaped with a stable camera frame.9 There
was a video recording error for one symptom evalu-
ation interview, resulting in a smaller sample size
(N = 15) for analyses utilizing this information.
Measures
Psychiatric symptomatology. All measures of psychia-
tric symptomatology were collected through struc-
tured interviews with trained research assistants.
Two measures of general psychiatric symptomatol-
ogy were administered. The Brief Psychiatric
Rating Scale (BPRS) is a general assessment
measure for symptoms. A total of 18 symptoms are
rated on a 7-point Likert scale. It was especially
developed as outcome measure to assess patients
change and it is widely used for assessing psychotic
symptoms (Overall & Gorham, 1962). The Global
Assessment of Function (GAF) is an assessment
scale from the Diagnostic and Statistical Manual of
Mental Disorders that scores symptoms and global
functioning of the person on a dimension from 1
to 100 with symptom benchmarks (4th ed., text
rev.; DSM-IV-TR; American Psychiatric Associ-
ation, 2000). The Scale for the Assessment of Nega-
tive Symptoms (SANS) was also administered in
order to specifically measure negative symptomatol-
ogy. The SANS is a common scale for the evaluation
of negative symptoms in schizophrenia (Andreasen,
1989). It assesses the presence and severity of nega-
tive symptoms across five domains: affective flatten-
ing or blunting, alogia, avolition-apathy, anhedonia-
asociality, and attention. We used the final global
score in this study.
Synchrony calculation. In order to calculate the
degree of synchrony across the interviews, we
462 L. Galbusera et al.

employed the Motion Energy Analysis software across all minutes in order to derive the synchrony
(Ramseyer & Tschacher, 2011; MEA version 2.06, measure for an entire interview.10 Figure 1 shows a
2011). This software allowed us to collect the sampling of the raw MEA values for each frame
frame-by-frame changes in specified regions of inter- across one minute of a single posttherapy interview,
est of a video frame. We specified two regions of plotting both the interviewer’s and the patient’s
interest for the analysis: the interviewer’s and movement.
patient’s whole body. Movement was collected at a
resolution of 15 frames per second for a maximum
of 15 minutes duration from the beginning of each
Results
interview. While most interviews were longer than
15 minutes and cut down to that maximum Changes in General Psychiatric Symptoms
amount, 14 (29.17%) interviews in our database and Negative Symptoms
were under 15 minutes. Of these shorter interviews,
Replicating previous research on BPT, we found
the average duration was 10:55 minutes (SD = 4:21).
decreases in general psychiatric symptomatology,
The MEA software provided time series of frame-
which reflected improvement after therapy. Paired
by-frame movement quantity in the regions of inter-
samples’ t-tests indicated a decrease in BPRS symp-
viewer and patient. In order to develop a measure
tomatology from before therapy (M = 2.05, SD
of overall synchrony across the entire interview, we
= .61) to after therapy (M = 1.70, SD = .46), t(15) =
further processed the simultaneous time series in an
−4.32, p < .001, d = −0.59, and an increase in GAF
algorithm modeled after the analysis of Ramseyer
score from before therapy (M = 57.25, SD = 13.67)
and Tschacher (2011). We calculated rolling cross-
to after therapy (M = 66.94, SD = 7.58), t(15) =
correlations at a time window of plus and minus 5
3.67, p = .002, d = 0.78.
seconds, which, at 15 frames per second of data, pro-
We also found that there was a significant improve-
duced a total of 151 correlations for each minute,
ment in negative symptoms. A paired samples t-test
ranging from the patient leading 75 frames to
indicated a decrease in negative symptoms on the
pacing 75 frames. These calculations were performed
SANS from before therapy (M = 27.25, SD = 13.27)
using the rollccf function found in the hydromad R
to after therapy (M = 18.88, SD = 10.84), t(15) =
package (Andrews, Croke, & Jakeman, 2011). Fol-
−2.85, p = .012, d = −0.68.
lowing, we averaged the absolute values of these
cross-correlations in order to establish the overall
synchrony for a given minute. These calculations
were made on distinct, minute-long windows that Changes in Interactional Synchrony
did not overlap. After producing these minute-level Testing to our second hypothesis, we examined
averages, we subsequently averaged synchrony whether interactional synchrony in both interviews

Figure 1. Frames of patient and interviewer MEA data over a sample minute.
Note: The gray line represents interviewer movement and the black line represents patient movement. MEA data were collected at 15 frames
per second, so 200 frames are equivalent to 13.33 seconds.

after therapy (the posttherapy interview and the
symptom evaluation) were different from the prether-
apy interview with a special contrast in a one-way
repeated-measures ANOVA model. We found that,
in fact, there was a significant effect in this contrast,
F(1, 14) = 4.91, p = .04, d = 1.18. Synchrony signifi-
cantly increased from the pretherapy interview to
the two interviews given after therapy. We had con-
firmed that the synchrony in interviews that were
shorter than 15 minutes was not significantly differ-
ent from those that were 15 minutes, t(45) = 1.23,
p = .23, d = 0.37, and had included these interviews
in the analysis.
Following, we explored the specific differences in
synchrony between the pretherapy interview syn-
chrony and the other two interviews individually.
Post hoc paired sample t-tests indicated that there
was a large difference in synchrony between the pre-
therapy qualitative interview (M = .07, SD = .02) and
the posttherapy interview (M = .09, SD = .02), t(15)
= 2.87, p = .012, d = 1.11. Figure 2 shows a compari-
son of the average synchrony for each minute of the
interviews for both the pretherapy interview and the
posttherapy interview. In this figure, one can see
both how the synchrony interviews are different and
how the average synchrony for each minute pro-
gresses dynamically across the 15-minute span.
However, there was no significant difference in
average interactional synchrony between the prether-
apy interview and the symptom evaluation (M = .08,
SD = .02), t(14) = 1.20, p = .25, d = 0.42. With no
Figure 2. Interactional synchrony during interviews over time.
Note: Error bars indicate high and low bounds of the standard error for each mean.
Psychotherapy Research 463
difference between the pretherapy interview and the
symptom evaluation in our post hoc tests, we uncov-
ered an important caveat to our positive findings
from the special contrast analysis: the change in inter-
actional synchrony appears contained to an increase
from pretherapy interview to the posttherapy
interview.
Correlation Between Changes in Negative
Symptoms and Changes in Interactional
Synchrony
We examined the degree to which reductions in
negative symptoms were correlated with increases
in synchrony. Since only those who increased in
synchrony after therapy could be said to have poten-
tially responded from the treatment in this dimen-
sion, we selected only those who responded with
increased in synchrony from the pretherapy inter-
view to the posttherapy interview for an initial
exploratory analysis (N = 14). Following, we corre-
lated pre–post changes in synchrony with pre–post
changes in negative symptoms. The change indices
for both measures were calculated by subtracting
the pretreatment values from the posttreatment
values. We found a nonsignificant negative corre-
lation in the predicted direction between synchrony
and negative symptoms among these respondents, r
(12) = −.51, p = .06. See Figure 3 for a scatterplot of
the values of these change indices. Given the small
464 L. Galbusera et al.
Figure 3. Scatterplot of the relationship between change in negative symptoms and change in interactional synchrony among the treatment
responder subsample.
Note: The gray area represents the 95% confidence interval of the regression line. Change indices for both measures were calculated by sub-
tracting the measure before treatment from the measure after treatment. For both indices, negative values indicate a decrease over time, while
positive values indicate an increase over time.
sample size for this analysis, we also examined this
relationship with a nonparametric correlation,
Spearman’s Rho, ρ(12) = −.45, p = .11, which
demonstrated a weaker trend. While these tests
did not reach statistical significance, they demon-
strated medium-to-large effect sizes. Testing the
same relationship with all patients (N = 16) resulted
in weaker, nonsignificant Pearson correlation, r(14)
= −.04, p = .89, and Spearman’s Rho, ρ(14) = −.27,
p = .31. The relationships between interactional
synchrony and negative symptoms were examined
for each time point as a cross-section. Pretherapy
interview synchrony and negative symptoms before
treatment were not significantly correlated, r(14)
= −.13, p = .63. Posttherapy interview synchrony
and negative symptoms after treatment were also
not significantly correlated, r(14) = −.02, p = .95.
Discussion
After 10 weeks of BPT intervention, schizophrenic
patients showed a significant improvement of
medium effect size (d = 0.59–0.78) in general psy-
chiatric symptoms and negative symptoms. In
addition, there was a strong (d = 1.11) increase in
interactional synchrony between interviews before
and after therapy with an important caveat that this
only applied to the more open-ended pretherapy
and posttherapy interviews conducted by the same
interviewer. In an exploratory analysis, we found
some initial evidence suggesting a possible large
inverse correlation between changes in interactional
synchrony and severity of negative symptoms; this
was not as robust given a reduced sample size and it
did not reach statistic significance (p = .06).
Changes in Psychiatric Measures and
Negative Symptoms
The results on general psychiatric symptoms and
negative symptoms improvement support previous
outcome studies on the efficacy of BPT which have
shown a significant decrease in negative symptoms
following the intervention (Priebe et al., 2013; Röh-
richt & Priebe, 2006; Röhricht et al., 2011). Impor-
tantly, previous clinical and randomized trials on
BPT not only have shown BPT to be more effective
than treatment as usual, but have also shown better
results than atypical antipsychotics (Röhricht &
Priebe, 2006). The outcomes of BPT are particularly
relevant if one considers the general lack of effective
treatment for negative symptoms, which often
remain a persistent and impairing burden in patients’
lives.
 Psychotherapy Research 465

Changes in Interactional Synchrony 2013; Kohler et al., 2008; Lavelle, Healey, &
McCabe, 2014a; Trémeau et al., 2005). Yet, most of
Supporting our hypothesis, we found a statistically
these studies have focused on the individual behavior.
significant increase in interactional synchrony from
Although some researcher have broadened the focus
the interview situation before therapy to the pooled
to interactional settings, they have still mainly measured
effect of both interviews after therapy. Considering
individual responses and behaviors (Kupper, Ram-
the two interviews after therapy separately in a post
seyer, Hoffmann, Kalbermatten, & Tschacher, 2010;
hoc comparison, we found some important caveat to
Lavelle, Healey, & McCabe, 2013, 2014a, 2014b).
this effect. A statistically significant increase in inter-
Using Bernieri and Rosenthal’s (1991) terminology,
actional synchrony was found when comparing the
one might argue that research on this topic has been
pretherapy interview with the posttherapy interview.
more concerned with the phenomenon of behavior
A slight increase in synchrony was also observable
matching rather than interactional synchrony.
between the pretherapy interview and the symptom
Recently, a few empirical studies have measured
evaluation, yet this increase was not statistically
the temporal dynamics of interpersonal coordination
significant.
(i.e., interactional synchrony), showing an impair-
The lack of significant results in interactional syn-
ment of social motor coordination in schizophrenia
chrony change for the symptom evaluation seems
(Kupper, Ramseyer, Hoffmann, & Tschacher,
likely due to the contextual and interpersonal differ-
2016; Raffard et al., 2015; Varlet et al., 2012).
ences introduced. Although the interviewers were
However, these studies have been implemented in
instructed to keep a loose conversational style, a
artificial settings such as the hand-held pendulum
review of the interview videos showed that the inter-
task or role-play situations. Our study makes a
actional context was still very structured, probably
novel contribution to this research strand, in that it
due to the structured nature of this interview protocol
investigates interactional synchrony in a less struc-
and the lack of interviewers’ training in qualitative
tured conversational setting. We believe that an
interviewing methods.
analysis of more natural interactions can better
In contrast, the pretherapy and posttherapy inter-
grasp the participatory sense-making phenomenon
views were conducted by the same interviewer and
and, more specifically, its disruption in schizo-
followed the same conversational and phenomenolo-
phrenia. Besides, this study investigates for the first
gical interviewing style. Interactional synchrony is a
time the phenomenon of interactional synchrony in
relational measure that captures coordination
schizophrenia within the context of psychotherapy
dynamics at the level of the dyad system; therefore,
outcome research. Thus, the focus was not on deficits
the amount of synchrony is constitutively dependent
but on the possibility of recovery and change within
upon both persons interacting. Since the personal
such dimension.
interaction style of the interviewer and the interac-
Ramseyer and Tschacher (2011, 2014, 2016) have
tional context of the interview were kept stable for
already shown a positive correlation between interac-
the pretherapy and posttherapy interviews, we argue
tional synchrony and psychotherapy outcome; in
that the significant variation in interactional syn-
their studies, which included a relatively wide spec-
chrony ought to be due to changes in patients’ inter-
trum of different disorders, interactional synchrony
action styles. This change in the patients’ bodily way
was generally associated with relationship formation
of relating can first of all be considered as an increase
and working therapeutic alliance. A correlation
in the temporal attunement of their own movements
between nonverbal synchrony and the quality of
to those of another person in face-to-face inter-
relationship has been confirmed by other psychother-
actions. Moreover, drawing on the notion of partici-
apy studies (e.g., Darwiche et al., 2008; Julien et al.,
patory sense-making, such behavioral changes can
2000; Koss & Rosenthal, 1997; Nagaoka & Komori,
simultaneously be understood as an increased relat-
2008). In a recent article, Koole and Tschacher
edness to the world and to others at the phenomeno-
(2016) have reviewed the empirical literature and
logical level. This might thus point to some recovery
have developed a theoretical interpersonal synchrony
of the intersubjective temporal attunement at the pre-
model of psychotherapy. According to this model, non-
reflective level. These findings acquire particular rel-
verbal synchrony supposedly creates an inter-brain
evance as they touch upon an essential aspect of
coupling which supports the establishment of the
schizophrenia, that is, a pre-reflective detachment
therapeutic bond.
from the social world.
The present paper confirms and contributes to the
In the last decade, several empirical studies have
already existing literature on the important role of
investigated nonverbal behavior in persons with schizo-
synchrony for psychotherapy outcome and relation-
phrenia, generally showing a diminishment or impair-
ship formation. Yet, we believe that, in the case of
ment of it (Brüne et al., 2008; Del Monte et al.,
schizophrenia, interactional synchrony might
466 L. Galbusera et al.
acquire a much deeper relevance. Before being an
indicator of relationship, it points to the contingent
dimension of embodied intersubjective “timing” or,
as Fuchs (2010) put it, the intersubjective temporality
which is at the core of the schizophrenic disturbance.
Interactional synchrony might thus be conceived as a
valid operational construct for grasping changes at
the intersubjective dimension of pre-reflective
engagement, thereby being an important indicator
of outcome for therapeutic change in schizophrenia.
The results of this study have been supported and
complemented by the findings of a parallel qualitative
study on the same BPT intervention. An in-depth
qualitative investigation of patients’ experience has
highlighted a recovery of patients’ spontaneous and
pre-reflective engagement with others after BPT
(Galbusera & Fellin, 2016). Moreover, embodied
intersubjectivity not only stands out as a crucial
aspect of therapy outcome but is also a core target
dimension of the therapeutic process in BPT. The
treatment manual (Röhricht, 2010) includes struc-
tured tasks that specifically target the implicit and
embodied intersubjective sphere: for example, regu-
lating interpersonal distances, perceiving one’s own
personal space, learning conversation-like patterns
through movement and mirroring exercises.
Besides, specific aspects of the therapeutic relation-
ship, such as a noninstructive, acknowledging and
authentic stance by the psychotherapist, have been
shown to play a crucial role in BPT change process
(Galbusera & Fellin, 2016). The integrated findings
of the present study and of the complementary quali-
tative investigation on the same BPT intervention
(Galbusera & Fellin, 2016) emphasize the impor-
tance of embodied intersubjective dynamics for the
process and outcome of schizophrenia treatment.
Interactional Synchrony and Negative
Symptoms
After examining the differences in interactional syn-
chrony and negative symptoms before and after the
BPT intervention, we explored the correlation
between the two. This analysis is based on the phe-
nomenological theory that negative symptoms might
be better conceived as being related to a core disturb-
ance of subjectivity and intersubjectivity rather than
being merely “removed” features of the disorder
(Parnas & Sass, 2001; Sass & Parnas, 2003).
Although these results did not reach statistic signifi-
cance due to the small sample size, they show a
strong negative correlation between severity of nega-
tive symptoms and interactional synchrony in those
patients who increased in synchrony (i.e., responded
to treatment in this way): it seems that the more
patients recovered intersubjective attunement and
synchrony, the less they scored on the negative symp-
toms scale. Similar results were found in a recent
study investigating interactional synchrony and
schizophrenia symptomatology, which has shown a
significant negative correlation between interactional
(head) synchrony and negative symptoms (Kupper
et al., 2016).
According to a phenomenological perspective,
negative symptoms should not be regarded as inde-
pendent entities but rather as co-constitutive of the
core disturbance of schizophrenia (Fuchs, 2013;
Parnas et al., 2013). These findings suggest an empiri-
cal relation between negative symptoms and a disorder
of intersubjectivity, thus supporting and confirming a
phenomenological view of schizophrenia. Although
the analysis presented in this paper is still explorative
and yet not sound enough to support any definitive
claim, it points to some interesting reflections on the
nature of negative symptoms in schizophrenia which
we believe are worthy of further research.
Limitations
This study aimed at assessing the efficacy of BPT by
using standard measures of symptoms and by intro-
ducing a new perspective which focuses on embodied
intersubjectivity as a core dimension of the schizo-
phrenic disorder and as the main locus of therapeutic
change in BPT. Due to the novelty of this approach,
this study is still to be considered as being of a pilot
and exploratory nature. In what follows, we outline
some important limitations that should inform and
improve further research on this topic.
First, although we consider the psychiatrists’ diag-
noses to be reliable, an additional standardized diag-
nostic test such as the Structured Clinical Interview
for DSM would have further enhanced the reliability
and validity of the study. Patients’ medication should
also be taken into consideration, as its side effects
influence patients’ attention, energy levels, nonverbal
behavior, and responsiveness. Different types of
medication might thus have had an effect on
outcome. Control over such variables should be
increased in future replications of this study.
Another critical issue is that the increase in interac-
tional synchrony from the pretherapy to the postther-
apy interview might have been influenced by an effect
of familiarization with the interviewer. Although we
could not rule out this effect, we believe that it is
made much weaker by the time gap of 10 weeks
between interviews. Yet, we do not know what kind
of bias familiarization may have on interactional syn-
chrony as, so far, no other studies have used repeated
measures of interactional synchrony with same dyads.

We acknowledge this potential limitation due to the
pilot nature of our study and we call for further
research to validate these results.
To conclude, two important limitations need to be
mentioned. First, this study did not include follow-up
assessments. This precludes the possibility of estab-
lishing if the changes observed after the BPT inter-
vention remain stable over time. Finally, due to the
absence of a control group, we cannot infer with cer-
tainty whether the findings are specifically related to
the effect of BPT model. Although the results on
negative symptoms and psychiatric assessment
measures confirm and support previous results of
empirical clinical research and randomized con-
trolled trials, the findings on interactional synchrony
and its relation to negative symptoms introduce new
insights on therapy for schizophrenia that still need to
be tested in additional trials.
Conclusion
In this study, we have investigated the efficacy of BPT
from a mainstream and a phenomenologically
informed perspective. First, we have confirmed that
BPT for schizophrenia effectively reduces patients’
negative symptoms and has an overall positive influ-
ence on patients’ psychiatric symptomatology.
Second, we have shown that BPT also seems to
affect the embodied intersubjective dimension, which
is crucial for the pathological definition of schizo-
phrenia. At the embodied intersubjective level, BPT
seems to yield a recovery of patients’ pre-reflective
social relations and intersubjective attunement,
which have been measured in this study through
bodily interactional synchrony. These findings
provide important evidence for the efficacy of BPT
and should be further investigated in future clinical
trials. Finally, by showing a relation between negative
symptoms and interactional synchrony, the present
study supports a phenomenologically informed holis-
tic view of schizophrenia, where negative symptoms
are conceived as components of a disturbance of sub-
jectivity and intersubjectivity. We believe that such
view should inform psychotherapy research in order
to yield a better understanding of the mechanisms
and outcomes of schizophrenia treatment.
Funding
This work was supported by the Marie-Curie Initial
Training Network “TESIS: Towards and Embodied
Science of Intersubjectivity” [grant FP7-PEOPLE-
2010-INT, 264828]; and a Deutscher Akademischer
Austauschdienst (DAAD) Predoctoral Research Fel-
lowship [Forschungsstipendien-lang 14/15].
Psychotherapy Research 467
Notes
1
Originally, the notion of participatory sense-making was intro-
duced by De Jaegher and Di Paolo (2007), who applied prin-
ciples of dynamic systems theory to the phenomenon of social
interaction. Fuchs and De Jaegher (2009) for the first time inte-
grated within this notion both a dynamic systems approach and
a phenomenological one.
2
The concept of mutual incorporation draws on Merleau-
Ponty’s (1962) notion of intercorporeality, which is described
as a fluctuation between one’s own embodied position and
the incorporation of the other’s lived body into one’s own sen-
sorimotor schema.
3
Indeed, the term interactional synchrony was coined by
Condon and Ogston (1966) for indicating nonverbal behavior
and coordination at the system’s level of the dyad.
4
For more details about the link between participatory sense-
making and interactional synchrony, see Galbusera (2016).
5
The reasons for the high dropout rate (36%) might be the con-
siderable effort demanded by the psychological testing and
interviews for the study. Indeed, besides the measures pre-
sented in this paper, additional tests were implemented for
other parallel studies. Some patients dropped out immediately
after the pretherapy tests and others did not take part in the
posttherapy interviews, although they participated in BPT.
Another reason for dropout was the intensive time schedule of
the BPT program, as some patients had difficulties to attend
all sessions.
6
Only one of the patients diagnosed with paranoid schizophrenia
had comorbidity with schizoaffective disorder (F25.1; F25.5;
ICD-10)
7
BPT sessions followed the structured format of the manual
guidelines. Each session was divided into five phases: an
opening circle, a warm up phase, a structured tasks phase, a
creative phase and a closing circle (for more information, see
Röhricht & Priebe, 2006). The 90-minute length of the sessions
thus allows enough time for all phases to be implemented.
8
According to the information given by the treating psychiatrists,
only two patients took part in work therapy and cognitive train-
ing during the BPT intervention (only partially overlapping);
few patients received occasional supporting meetings with a
psychotherapist.
9
For motion energy analysis, the camera frame should remain
stable to avoid any spurious detection of movement.
10
Our only departure from Ramseyer and Tschacher (2011) was
not standardizing the individual motion energy time series
prior to the synchrony calculation. Performance of a Pearson
correlation already functions as a standardized metric; standar-
dizing individual time series has no effect on the final correlation
values.
ORCiD
Michael T. Finn http://orcid.org/0000-0003-2490-
2562
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