British Journal of Medical Psychology (2001), 74, 23–33 Printed in Great Britain 23

q 2001 The British Psychological Society

Psychosis and the disintegration of dialogical

self-structure: Problems posed by schizophrenia
for the maintenance of dialogue
Paul H. Lysaker*
Roudebush V A Medical Center and the Indiana University School of Medicine, USA

John T. Lysaker
Department of Philosophy, University of Oregon, USA

Researchers and theoreticians across widely varying disciplines have increasingly

stressed how sense of self is inherently ‘dialogical’, or the product of ongoing dialogue
both within the individual and between the individual and others. This perspective
emphasizes that self-awareness is not an awareness of an isolated or seamless viewpoint,
but a collective of numerous complementary, competing, and sometimes contradictory,
voices. In this paper we suggest that changes in subjective sense of self in schizophrenia
spectrum disorders may represent the collapse of this essential dialogue. We suggest
that this collapse can have the end-result of mentally ill persons either coming to
embrace a singular, all-incorporatingself-position or standing precariously on the brink
of cacophony which is experienced as self-dissolution. We point to two phenomena
associated with schizophrenia that could contribute to the derailment of internal and
external dialogue: impairments in associative processes and affect dysregulation.
Illustrated with a case example, we Žnally suggest how psychotherapy has the potential
to revive internal dialogue through its explicit use of external dialogue helping to
restore previous levels of social function.

F. was a man in his early 20s who lived with family and attended college nearby. He was
the youngest child born to an intact family in north-eastern USA. His father was a
salesman and his mother a homemaker. F. had been an average student in high school. He
dated regularly in adolescence and routinely socialized with a group of close friends. F.’s
father had a history of depression but had refused treatment because he believed that
people should ‘handle their own problems’. F. himself experienced depressive symptoms
in early adolescence and believed that they resulted from his father’s gross withdrawal
from the family.
F. had been a patient in individual psychotherapy with one of us (P.L.) for almost 2
years. The issues for which he had initially sought treatment included his struggles to
separate from his family resolving anger at his father for his withdrawal from F.’s life,
forgiving his mother for not divorcing his father, and achieving intimacy with a

*Requests for reprints should be addressed to Paul Lysaker, Day Hospital 116H, 1481 West 10th St, Roudebush VA
Medical Center, Indianapolis, Indiana 46202, USA (e-mail: Lysaker.Paul_H_PHD@Indianapolis.va.gov).
24 Paul H. Lysaker and John T. Lysaker
girlfriend. He presented as an intelligent person with a dry sense of humour but with
little sense of personal direction or motivation. Then, suddenly, immediately following
an extended vacation, F. became acutely psychotic. In a short period of time F. changed
dramatically. All previous issues became irrelevant and F. was a frightened and
argumentative man, utterly consumed with the belief that a former teacher was arranging
his assassination.
Despite immediate pharmacological intervention, the psychosis did not remit and as
time wore on a clinical picture meeting criteria for schizo-affective disorder developed.
For the next few months the focus of psychotherapy shifted radically. Interventions
focused almost exclusively on reassuring F., helping him to accept anti-psychotic
medication, and providing support to his family.
At a turning point in his recovery, F. ‘blew up’ and accused me (P.L.) of being a ‘traitor’.
He was furious because I had remained neutral and would not afŽrm the reality of his
delusional concerns. When I asked F. about the angry tone of his remarks, he said that he
thought that I was the angry one because I stubbornly refused to see the danger he was in.
As he pressed me further, I explained that more than anything else I felt confused. ‘We
once talked about your ideas and feelings, but now you only can think and talk about ‘x’
(his persecutor) . . . it’s impossible to talk about anything else.’
In response, F grew silent and for the Žrst time since his psychotic break, seemed
inexpressibly sad. In a downcast and defeated manner, he acknowledged that being
persecuted was all he could think about. He added that those thoughts were ‘necessary’.
He explained that if he stopped thinking about his persecution, he was consumed by
unbearable feelings of ‘emptiness and nothingness’, a subjective state inŽnitely more
painful than being persecuted.
Many have observed that persons with schizophrenia spectrum disorders experience
alterations in personality (Selzer & Schwartz, 1994). Schizophrenia has been linked, for
example, to an erosion of feeling able to direct one’s life (Lysaker & Bell, 1995), to
overwhelming anxiety about self-dissolution (Frosh, 1983), and to disruptions of
personal narrative (Kline, Horn, & Patterson, 1996). Less clear in the literature, however,
is how we should understand subjective changes in self-experience. What do they reect?
How are they linked to other aspects of illness? While psychiatric research has proposed
that acute symptomatology is ultimately the result of a host of neurodevelopmental and
biochemically based processes (e.g. Borgerts, 1997; Olney & Farber, 1995), less has been
written about how such processes alter sense of self. How can we explain why F.,
previously a complex person, suddenly experienced himself and could relate to others
solely as the desperate subject of persecution?
To address this issue, we will attempt to evolve an account of what happened
phenomenologically in the case of F. First, we will review theory and research suggesting
that the self is best described as a series of internal and external dialogues. Focusing
on F.’s Žrst-person report, we will then argue that his psychosis could be
conceptualized as the disruption of internal dialogue associated with neurocognitive
deŽcits, limiting him to a univocal sense of self determined by feelings of persecution.
Continuing F.’s story, we will Žnally describe how psychotherapy may have
facilitated recovery by helping to reignite F.’s internal dialogue through external
dialogue, and discuss the implications of this for the psychotherapy and rehabilitation
of schizophrenia.
 Psychosis and self-structure 25
Theories of the dialogical nature of self-aw areness

Over the last century, theorists have increasingly stressed the dynamic and multifaceted
nature of subjective sense of self. According to investigations across widely varying
disciplines, the self is inherently ‘dialogical’, or the product of ongoing dialogue both
within the individual and between the individual and other individuals. This view
emphasizes that self-awareness is not an awareness of an isolated single voice or a seamless
viewpoint, but a collective of numerous complementary, competing, and sometimes
contradictory, voices and beliefs. The self here is importantly not only an awareness of this
collective but also the experience of moving between various points within the collective.
The concept of the dialogical self or ‘dialogism’ is derived from several sources. Most
popularly, dialogism has been linked with the work of the Russian literary critic Bakhtin
(1929/1985). Developed from his readings of the works of Dostoyevsky, Bakhtin argues
that the human world is most truly represented as polyphonic, or as an ongoing series of
dialogues between opposing voices. He argues that Dostoyevsky’s use of dialogue to
examine the psyche is not merely an advance in ‘artistic thinking’ but also an advance in
understanding ‘thinking human consciousness’ (p. 270). He suggests that Dostoyevsky’s
œuvre provides revolutionary insights into the psyche by offering open and continuous
dialogues between opposing characters instead of a singular conclusive perspective. More
recently Wortham (1999) has made similar points about the dialogical nature of the
psyche. He points out how in autobiography the self is both the narrator and main
character whose dialogue reveals more about the subject than either alone.
Preceding Bakhtin, Nietzsche (1886/1966), also claimed that the self is best described
as a ‘common wealth’ or ‘a social structure composed of many souls’ (p. 26). He explained :
‘‘the way is open for new versions of the soul hypothesis; and such conceptions as ‘soul as
subjective multiplicity’ and soul as social structure of drives and affects’’ (pp. 20–21).
The suggestion here is that the self is an ensemble, driven by habits and desires, which
share the same body but lack an overall integrating function. In fact, Nietzsche rejects the
existence of any overarching self that oversees or conducts the multiplicity of voices
which people live out. He writes: ‘‘With regard to the superstitions of logicians, I shall
never tire of emphasizing a small terse fact: that a thought comes when ‘it’ wishes not
when ‘I’ wish, so that it is a falsiŽcation of the facts to say that the subject’s ‘I’ is the
condition of the predicate ‘think’ (p. 24). The point here is that we are led by our
experiences to suppose that a uniŽed agent is responsible for cognition, which we call the
self, even though there is no real evidence that our thoughts are our creation, rather than
the other way around. As Hume (1739/1964) noted years earlier : no matter how
thoroughly we introspect we never Žnd the ‘I’, only bundles of thoughts or ‘perceptions’
(p. 252).
If no singular self underlies the multiplicity of internal experience, then the question
naturally arises : why the persistent search for an organizing unitary self? Nietzsche
suggests at least two answers. First, the singular self may be a mirage, the result of a trick
of grammar. Grammatically speaking, just as singing requires a singer, thinking seems to
require a thinker, thus making it easy to erroneously suppose that a unitary self must
exist. A second and more illuminating possibility is developed in The gay science (1887/
1974). Here Nietzsche proposes self-awareness developed ‘‘under the pressure of the need
for communication’’, and that ‘‘consciousness is really only a net of communication
26 Paul H. Lysaker and John T. Lysaker
between human beings’’ (p. 298). Here he suggests that in order to ourish, people had to
develop ways of communicating the presence of needs, threats, opportunities, and that
effective communication about these matters required a shorthand in which ‘I think’ was
used as a sign for complicated internal processes. Thus, people have searched for a singular
identity because they have ‘forgotten’ that ‘I think’ was a sign which marks evolutionary
progress and not direct evidence of a univocal self lying behind cognition.
Nietzsche’s notion that consciousness developed out of communication contains a Žnal
theoretical point: it places along a continuum the internal and external facets of the self.
By Nietzsche’s account, internal dialogue develops out of dialogues with others. He
writes : ‘‘The human being inventing signs is at the same time the human being who
becomes even more keenly conscious of himself’’ (p. 299). In other words, internal
polyphony diversiŽes and develops in response to social demands. This observation
preŽgures developments in the USA shortly thereafter. Mead, for instance, insisted that
‘‘no hard and fast line exists between our selves and the selves of others since our own
selves exist and enter as such into our experience insofar as the selves of others exist and
enter into our own space’’ (1934, p. 164). Focusing more on behaviour than mentation,
Dewey (1925/1988) similarly comments that ‘‘communication not only increases the
number and variety of habits, but tends to subtly link them together’’, enabling them to
acquire increasing levels of distinctiveness (p. 214).

Contemporary research on the self as dialogical

While work on the self as dialogue by other disciplines dates back well into the last
century, research in psychology and allied Želds has only recently begun to systematically
study the self as an interaction of opposing voices or positions. Hermans alone (1996) and
with colleagues (Hermans, Rijks, & Kempen, 1993), has extensively studied personal
narratives as manifest in structured interviews. He concludes that the individual psyche
contains opposing self-positions or voices that are not centrally integrated but are
hierarchically arranged, that is, that at any one time the psyche is composed of positions
or voices that are dominated by others but not subsumed by them. Studying individual
positions as they exist in relation to one another within the psyche, he concludes that the
hierarchy of positions spontaneously and routinely reverses itself with the result that the
self is perpetually shifting between positions in a dialogical manner.
Gregg (1995) has also investigated the dialogical self using semi-structured interviews
and has observed regular dialogical shifts within awareness of the self. He suggests that
these shifts are the basis of our experience of self-depth. He also proposes that those shifts
occur in speciŽc ‘places’ within the self. He proposes that there are ‘‘multistable or
structurally ambiguous’’ symbols from which self-deŽnition can naturally move in a
number of opposite directions (p. 617). These symbols are speciŽcally points of self-
deŽnition that naturally occur along the continuum of everyday thought which have
strong associational links with other positions, including ones which are diametrically
opposed to one another. Thus, the dialogue which sustains the self is made possible by
certain key symbols which function as conduits through which self understanding can
ow in one direction one day and in another on the next, without regard to how
contradictory those positions might be.
A second avenue of research on the dialogical self has grown out of literature on
 Psychosis and self-structure 27
narrative (e.g. Bruner, 1986; Sarbin, 1986). Various authors have argued how trauma
(Wigren, 1994), substance abuse (Klion & Pfenninger, 1997), neurocognitive impair-
ment (Lysaker & France, 1999; Palombo, 1993) and faulty psychiatric care (Bebout &
Harris, 1995) adversely affect self-narratives, ultimately eroding self-awareness and social
function. Complementary research suggests that empathic support within psychotherapy
can help repair narrative, reducing the discomfort linked to internal incoherrence
(Goncalves, 1994; Mishara, 1995; Neimeyer, 1994; Omer, 1997). Underscored here is
how the dialogical nature of narrative is revealed in psychotherapy and how rents in that
dialogue are attended to through the dialogue between the psychotherapist and patient
(e.g. Russell & Van Den Broek, 1992). Thus we see again the continuum observed by
Nietzsche in which internal and external facets of the self participate in, and are made
possible by, ongoing dialogues.

Psychosis as the collapse of the dialogical self

What are the implications of all this for the disturbances of self we observed in
schizophrenia spectrum disorders and in F.’s case? We propose that, for many, the
experience of psychosis can be conceptualized as a breakdown of dialogue within the self
and between self and others. For F., psychosis clearly marked a state in which he could no
longer experience himself or communicate with others as someone composed of an
interacting amalgam of thoughts and feelings. He had previously been someone who was
ambivalent about his lover, a caring person with a paradoxically sadistic sense of humour,
someone who needed his father’s approval while resenting his father’s weaknesses. With
the onset of F.’s psychosis, all of this collapsed. Suddenly his access to other positions was
blocked or derailed. The constant shifting of ideas/voices of the self that Hermans (1996)
and Gregg (1995) describe ceased. F. had strictly one voice : he was the victim of a
persecutor. The extreme quality of this one position was highlighted by F.’s description of
how he could only be persecuted or be nothing. Identity was deŽned here only by
reference to an external Žgure with whom dialogue was impossible. Perhaps with the
collapse of internal dialogue there was a retreat to external Žgures for deŽnition.

Cognitive impairments and threats to dialogical identity in schizophrenia

To understand the virtual cessation of F.’s internal dialogue, it seems reasonable to begin
by examining how F. experienced this process. First, given the considerable agony he
expressed on numerous occasions, F. clearly experienced this collapse as something
beyond his control, and as something that he had not chosen. Further, when he spoke of
his previous self he indicated that he felt as if it had been ‘destroyed’, and on one occasion
likened himself to a planet which had been ‘blasted into fragments’.
Did internal dialogue cease because internal self-positions were destroyed? Since, as we
will describe shortly, F. was eventually able to resume an internal dialogue that resembled
his old one, it seems clear that previously accessed self-positions (that is, the basic
components of the self and constituents of internal dialogue) were not destroyed. But why
then the metaphor of a destroyed planet? One parsimonious explanation is that F.’s
psychosis represented a state, not one in which self positions were destroyed, but one in
28 Paul H. Lysaker and John T. Lysaker
which access to those positions was disrupted. Perhaps internal conversation was no
longer possible because F. was suddenly unable to access or ‘Žnd’ the self-positions that
had previously been conversant with one another.
But what process could block access to previously accessible self-positions and
consequently impede dialogue? We suggest that there are at least two different and
non-mutually exclusive answers. First, in the tradition of Bleuler (1911/1950), it is
possible that disturbances in associative processes could compromise the dialogical self.
Disturbances in associative processes are considered to be among the forms of cognitive
impairments (Bell, Lysaker, Milstein, & Goulet, 1994) closely associated with functional
deŽcits (Carter & Flesher, 1995; Lysaker, Bell, Zito, & Bioty, 1995) and recently
hypothesized to compromise the continuity of self experience (Helmsley, 1998).
Disruption in associative processes refers to the tendency to inadvertently ‘jump’ or
skip over ideas naturally associated with one another when thinking or talking, and
instead to think or verbalize ideas distantly or ‘loosely’ related to the original thought.
Spitzer (1997), for example, has demonstrated how people with schizophrenia, when
attempting to move from an idea called ‘a’ to a naturally associated idea called ‘b’,
inadvertently pass over ‘b’ and land on ‘d’ instead (‘d’ being an association of ‘c’, and ‘c’ an
association of ‘b’).
Such a disruption in associative processes would almost necessarily disrupt movement
between self-symbols. Consider the following example: a betrayal generates an internal
dialogue between two self-positions : ‘‘I am owed retribution’’, and ‘‘I am forgiving’’.
When exploring the tensions between the two positions, a disruption occurs and a
distantly related self-position ‘self as expert chef’ enters into the conversation (‘self as
expert chef’ as an association of ‘self as entertainer’, which is associated with ‘self as
generous’ which associated with ‘self as forgiving’). At that point, the coherence of
internal dialogue would be severely threatened (particularly if ‘self as expert chef’ opened
into further associations) and the polyphony of familiar opposing voices would begin to
shift unpredictably, resulting in cacophonous self-experience akin to a dream in which
one is walking from one room to another and then is suddenly in a different time and
place.
The implication is that F.’s internal dialogue may have ceased when his ability to move
reliably between self-symbols was disrupted. With the associative links between his self-
symbols imperilled, we suggest that F. found himself able to maintain internal
consistency only by remaining on a single set of self-symbols. Furthermore, having to
embrace only one self-symbol, this self-symbol naturally became a condensation of other
symbols, one best abbreviated as ‘self in dissolving’, anchored only to an external deŽning
feature. In other words, faced with the threat that internal dialogue would throw him
into an unpredictable and disconcerting set of self-symbols, F. opted to remain on one
position, a position that was a condensation or a non-interacting amalgam of various self-
symbols. His self changed from dialogue to a monologue in which there was no longer a
collective self or experience of moving between various points within the collective.

Overw helming affects and threats to dialogical identity in schizophrenia

It seems important to note that the singular self-position that emerged from F.’s psychosis
was invested with enormous quantities of affect. This raises at least two possibilities.
 Psychosis and self-structure 29
First, it is possible that this affect resulted from the collapse of the dialogical self. Perhaps
the collapse of dialogue blocked the usual ways F. expressed affect, leaving him with
oceans of affect expressed only in bursts. Perhaps he grew angry as a way to organize
internal experience in the ensuring chaos (Eigen, 1986). A second possibility, however, is
that affect was additionally related to the arrest of dialogue. From the psychoanalytic
tradition, several authors have suggested that the impairments associated with schizo-
phrenia result from anger or aggression that overwhelms the psyche (e.g. Klein, 1946;
Spotnitz, 1987). Frosh (1983) has similarly suggested that the experience of the self on
the brink of dissolution may result from enormous anxiety that can be generated by
‘defect’ rather than conict.
Thus there is precedent to suggest that affect, created or made available by the illness,
may be linked with the disruption of internal dialogue. It would, in fact, make sense
intuitively that such strong affects could bind previously distinct self-positions together
or provide an environment in which dialogue between them would not make sense.
Given that personal narratives are believed to be a means of organizing affects (Russell &
Van Den Broek, 1992), it is also possible that an inux of unusually strong affects could
disrupt the organization of the self-positions whose conversation constitutes narrative.
Thus, in addition to having to struggle with impairments in associative processes, F.’s
psychosis may have also given him the task of integrating within existing self-positions
large quantities of affect, increasing stress on already compromised cognitive faculties and
hastening the collapse of the dialogical self.

Recovery and the re-emergence of dialogue

To relate only the collapse of F.’s internal dialogue is to tell half the story. At the moment
F. explained that his alternative to being persecuted was being empty and broken, another
voice or self-position was introduced into the drama: there was the self as persecuted and
as an observer of that dilemma. As a consequence, there was again, simply put, something
to talk about. Dialogue, internal and external, was once more possible.
Indeed, from this date onward, despite numerous setbacks, increasing numbers of self-
positions arose during treatment including self as ‘angry at parents’, ‘wounded’, ‘bored’,
‘musically talented’ and ‘certain to fail’. Furthermore, these positions were able to exist
contemporaneously and in dialogue with one another. Interestingly though, no dialogue
was ever observed between these positions and ‘self as persecuted’, suggesting that at that
stage of recovery F. was oscillating between a monophonic and dialogical self. While F.
periodically stopped taking his medication and changed jobs repeatedly, these other
positions proved relatively stable and formed the basis of long and productive conversa-
tions in therapy and with family and friends. There was again an awareness of a collective
of self-positions and the experience of moving between various points within the
collective.
After 2 years, F.’s paranoia ceased, almost as abruptly as it had started and the voice of
‘self as persecuted’ vanished. Without clear precipitant, F. no longer felt in danger, and
attributed his previous paranoid thinking to ‘sickness’. When pressed to explain, he
Žnally explained that he thought that his delusional belief had served the following
purpose: ‘‘it was like a planet exploded and they (feelings of persecution) were the gravity
that kept the fragments from ying off and being lost’’. Maintained on medication,
30 Paul H. Lysaker and John T. Lysaker
F. enrolled in a community college and performed adequately despite a lingering thought
disorder and some negative symptoms. He also took up and pursued some of his old
hobbies. He Žnally left psychotherapy a year later when his family moved away. For the
record, we do not think we could say F. returned to being the ‘same person’. Dialogue
with him was never again as rich or uid. When asked for his opinion here, F. himself
agreed. He reported a lingering sense that he was not ‘who he used to be’. Although we
were never able to understand completely what he meant, our best sense is that F.’s
thinking about himself retained an odd and disjoined quality as the leaps made between
self-positions were never again as sure-footed as they once were. Thus, although many of
his ‘old’ self-positions were ‘resurrected’, dialogue between the positions remained
strained and, therefore, less productive. Our impression was that his internal dialogue
continued to be subject to interjections from loosely associated self-positions that served
only to confuse and disperse the conversation.

Psychotherapy and the repair of the dialogical self in psychosis

The progress in F.’s treatment raises numerous issues, not least among them: what
allowed the new/old voices to take shape and what allowed these other voices to persist
even though his paranoia had not abated? We would suggest that one parsimonious
answer to these questions is that other positions were reintroduced and sustained through
dialogue in psychotherapy. As cited above, writers as disparate as Nietzsche and Bruner
have suggested that dialogue begins between persons and then only later exists as internal
dialogue. We would suggest that F. used the dialogues that comprised his psychotherapy
to map out his self-positions, as a place to store crucial information about their
coordinates so they could be recovered if temporarily lost. He may thus have used his
psychotherapist as a kind of cognitive prosthetic, someone who could remember his key
self-positions, make them available to him when he had forgotten them and, as such, also
act as a coach in the art of dialogically moving between self-positions. With regard to his
intense affective states, F. may also have used his psychotherapeutic dialogue to process
his extreme emotional states and to reintegrate those within narrative as well. Note
that this is consistent with the work of others (e.g. Vygotsky, 1978; Wertsch, 1985), who
have written extensively about the construction of internal experience through social
interactions.
It has long been a goal of the psychotherapy of schizophrenia to create an enhanced or
shared narrative (Haugsgerd, 1994; Holma & Aaltonen, 1995; Lysaker & France, 1999),
and to process unbearable affects (Frankel, 1993; Karon & Van Denbos, 1981). The
implication of our observations about F. is that these two processes may be conceptualized
as active therapeutic ingredients by virtue of their impact on the dialogical self.
Reections made when dialogue has lapsed and a monophonic stance is dominant may
reopen the dialogical self by reminding patients of alternative positions that have lapsed.
In this sense, perhaps like a conductor, the therapist ultimately reminds the person with
schizophrenia to remain cognizant of other musicians playing alongside him or her, and
of the full range of notes available to them, through regular feedback, exercises or
rehearsals.
The role of psychotherapy in the rehabilitation of persons with severe mental illness
has become increasingly controversial in the last decade (Lysaker & France, 1999). With
 Psychosis and self-structure 31
increasing attention paid to rapidly evolving interventions such as vocational rehabilita-
tion and social-skills training, little has been written about the unique role psychotherapy
could play in comprehensive treatments. Implicating the collapse of dialogue in psycho-
social dysfunction and conceptualizing psychotherapy as a means to revive this dialogue
may point to new ways of involving psychotherapy in rehabilitation.

Internal dialogue and other forms of symptomatology

Schizophrenia spectrum disorders are heterogeneous in nature and there is probably
considerable variability in their phenomenological underpinnings. Thus we would not
want to suggest that the collapse of the dialogical self is related to all possible forms of
this disorder.
In this paper we have focused in particular on the possible relationship of delusions and
paranoia to the collapse of dialogical self. Clearly there are other dimensions of illness,
including negative symptoms, and other forms of delusions and hallucinations whose
relationship to dialogue we do not have the space to explore fully in this paper. We would
briey suggest though that there are intuitive reasons to think these features of illness
may also be linked to the collapse of dialogue and that further exploration of these issues
is warranted. One recent paper (Davies, Thomas, & Leudar, 1999) has already explored
how the concept of the dialogical self can be used to understand hallucinations in
schizophrenia. Indeed, it makes sense rationally to think that auditory hallucinations,
particularly voices which discuss, comment and command, could be conceptualized as
self-positions disembodied or detached by cognitive features of illness. This is consistent
with psycho-analytic observations that hallucinations often appear as means of warding
off the total destruction of the self by placing elements of self outside of the self (Eigen,
1986). With regards to negative symptoms including avolition, it also makes intuitive
sense to suggest that the inability to direct one’s life (Lysaker & Bell, 1995) represents a
state in which internal discussion of matters of one’s future have been derailed.

Conclusions
In this paper we have offered a conceptualization of some of the phenomenological
changes that take place in schizophrenia spectrum disorders. Illustrated with the case of a
patient intensively treated prior to and following the onset of illness, we have suggested
that the disruptions in associative processes and affect dysregulation linked with the
schizophrenias may profoundly interfere with internal and external dialogues, and
ultimately the maintenance of identity. We have also suggested that the dialogues
which psychotherapy consists of represent an intuitively appealing route by which to try
and resuscitate such collapsed dialogues. This line of thinking is consistent with
rehabilitation literature linking enhancements in sense of self to recovery (Davidson,
1999; Davidson & Strauss, 1992; Polkinghorne, 1995) and may point to a variety of
potentially adjunctive treatments aimed at enhancing rehabilitation outcome.
There are many unanswered questions here as well as limitations to this paper. We have
focused on a single case— one in which we had the unique experience of knowing the
patient well before and after the onset of psychosis. It is therefore not clear how the
relationship of psychosis and dialogical self-structure should be understood in persons
32 Paul H. Lysaker and John T. Lysaker
whose form of mental illness is radically different from that of F. For example is a similar
process at work in persons who view their psychosis as an asset, as in the case of some
people whose psychosis is associated with beliefs in supernatural abilities? Additionally,
there are numerous phenomena linked with psychosis whose nature might be better
understood in the light of explorations of the relationship of psychosis to the dialogical
self. These include, among other things, the often noticed link between madness and
creativity.
Clearly, considerable amounts of work are necessary in this area before Žrm conclusions
can be reached. In particular, systematic research is needed, including formalized
assessments of the dialogical structures of people with schizophrenia, as well as
qualitative and quantitative analyses of the psychosocial, neurocognitive and psychosocial
correlates of internal and external dialogue in this disorder.

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Received 14 April 2000; revised version received 18 August 2000