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Journal of Constructivist Psychology, 19:191207, 2006

Copyright Taylor & Francis Goup, LLC


ISSN: 1072-0537 print / 1521-0650 online
DOI: 10.1080/10720530500508936

DISORGANIZED NARRATIVES:
PROBLEMS IN TREATMENT AND
THERAPIST INTERVENTION HIERARCHY

GIAMPAOLO SALVATORE, LAURA CONTI,


DONATELLA FIORE, ANTONINO CARCIONE,
GIANCARLO DIMAGGIO, and ANTONIO SEMERARI
Terzo Centro di Psicoterapia Cognitiva (Training school in psychotherapy),
Associazione di Psicologia Cognitiva (APC), Rome, Italy

The way in which patients tell therapists their stories has an impact on treat-
ment. They try to put their emotions and the events generating them, their
goals and the behavior they adopt to achieve them, and so on, together in a
coherent discourse. But some patients fail in organizing their narratives. They
might describe a diffuse arousal without letting the reasons for their discomfort
be known, switch from one subject to another without any apparent connec-
tion, or pile up one topic after another, thus overwhelming a listener, who is
unable to see which is the main one. We call such narratives disorganized.
They do not help a patient to make sense of experience or achieve consistency
in behavior. A therapist listening has difficulty in planning treatment and
often reacts negatively to such patients. Here we propose a series of interven-
tions aimed at improving narrative coherence, creating a sound therapeutic
relationship and making treatment effective. We will describe the therapy with
a seriously dissociated patient in which this intervention has proven useful.

With story-telling we are able to make sense of inner experience


(Angus & McLeod, 2004; Bruner, 1990), make choices (Johnson-
Laird, 1983), ascribe meaning to others behavior and relate with
them (Gonalves, Korman & Angus, 2000; Hermans, 1996). Nar-
rative is a format organizing sensory experience in order to make

Received 4 September 2005; accepted 25 November 2005.


Address correspondence to Giampaolo Salvatore, c/o Terzo Centro di Psicoterapia
Cognitiva, via Ravenna 9/c 00161 Rome, Italy. E-mail: terzocentro@iol.it

191
192 G. Salvatore et al.

it comprehensible to the individual and capable of being com-


municated to others (Kelly, 1955; Neimeyer, 2000). Starting with
emotional cores, various elements of experiencememories, mental
images, social rules, and potential futuresjoin together and become
stories (Salvatore, Dimaggio & Semerari, 2004), which then cre-
ate and continuously update ones autobiographical memory and
personal identity (Bluck, 2003; Singer & Blagov, 2004).
Patients tell stories for their therapists to hear their suffer-
ing and give it a meaning, and to comfort them. In other words,
through a good story a patient is able to communicate his/her
problematic experiences and seek help. For a therapists inter-
vention to be successful a patients discourse needs to clearly
depict somatic experience, the events generating emotions, ac-
tion tendencies, life plans, and goals. A fundamental feature that
patients need to acquire in their stories is a superordinate point
of view giving meaning to variations in their discourse and to
shifts in their forms of experience. This is what gives us, for
example, the feeling that we have a consistent identity if first we
are rough and pugnacious at work and later we become tender
and gentle with our children. A point of view of this sort is a sign
of good metacognitive skills, that is, the ability to describe ones
behavior and that of others in psychological terms, to reason
about it and to use this knowledge for solving problems and
fostering adaptation (Semerari et al., 2003).
Some patients fail to organize the elements making up their
experience into a consistent discourse. Dimaggio and Semerari
(2004) name such narratives disorganized:

patients [. . .] relate stories that are confused, disordered and incompre-


hensible, characterized by thought themes and emotions that get mixed
together without any apparent sense. They may provide descriptions of
the same character that are intense and at the same time the opposite
of each other and mutually incompatible, or they may open an infinite
number of parentheses without ever closing them, while hundreds of
characters come onto the stage competing with each other for the floor
[. . .] even if a patient has a wide range of representations of the self-
other relationship at his/her disposal, he/she is unable to account for
the rapid and difficult-to-understand transitions that occur when passing
from one mental scenario to another. (p. 267)

Here is an example of disorganized narrative, from the be-


ginning of the psychotherapy of Lucia, who complies with the
Treatment of Disorganized Narratives 193

diagnostic DSM-IV criteria (American Psychiatric Association, 2000)


for Dissociative Disorder N.O.S.

I realized, for example, that Id not shown up at work for four days.
This went on, and I remember I didnt go out of the house. Then I was
obliged to go back to work. Clearly I wasnt in the best of health . . . I
kept wanting to escape . . . on Friday, when I came back from the office,
at a certain point I picked up my things and left because my mind was
on making a bit of an end to everything, but I couldnt find the best
way. I mean that the image made me laugh. Deaths have always made
me laugh whenever Ive had first-hand experience of them. I mean,
when my brother-in-law died. It was really tragic . . . I was there right up
to the end, but then at the end I started laughing. My father, for ex-
ample, died alone with me and then, you know, at the funeral I felt like
laughing. I mean, the image of my own death too, in a certain sense.

The narrative themedeathis clear, but not the way in


which the elements are organized. Actions mainly take the form
of avoidance behavior and start without reason (Id not shown
up), her emotions are out-of-place (the image made me laugh)
and her intention not clear: what is she asking the therapist for?
On reading this extract her therapist (and the reader probably)
feels disorientated: Why did Lucia stay shut up at home? What
caused her suicidal thoughts? Why did she leave her job? How is
that tragic events make her smile?
When faced with a disorganized narrative, therapists do not
feel inclined to attune and offer help but, on the contrary, are
likely to feel confused like their patient. If the patient, moreover,
expresses a vague but emotionally compelling request for help,
therapists realize the urgency there is in giving comfort, without,
however, knowing how to proceed. The swinging between confu-
sion and care-giving disorients therapists and makes their action
ineffective.
Starting with an analysis of Lucias therapy we are going
to describe: (a) how the root cause of patients disorganized nar-
rative is their difficulty in using their emotional experience to
organize discourse; (b) what problems disorganization poses
for treatment right at its very earliest stages; and (c) what a thera-
pist should do to tackle them. Our hypothesis is that a well-
conducted therapy can reduce the disorganization and that cer-
tain specific interventions can be effective right from the start of
treatment.
194 G. Salvatore et al.

Lucias History1

Lucia is 45 years old, was born in a village in central Italy and is


the youngest of four children. After her high school certificate
she enrolled at a big city university. Here she met her future
husband, of Middle Eastern origin. As soon as she married, she
realized she was not loved. She hoped, nevertheless, that the
relationship would provide her with stability and affection. Her
husband suddenly decided that they should move to his country
of origin. There their relationship became emotionally detached
and cold. After several years there, her husband decided they
should go back to Italy, where he started his vocational educa-
tion again. Lucia went to work to support them economically.
Their marriage entered a crisis, and they ended up separating, at
which point Lucia dedicated herself heart and soul to her work.
A few months later she asked for psychotherapy. She was treated
by a therapist (A.S.) with long experience in treating patients
with serious dissociative and personality disorders (Dimaggio, Semerari,
Carcione, Nicol, & Procacci, 2006) and who focused on the
narrative reorganization of experience (Angus & McLeod, 2004;
Neimeyer, 2000).
When Lucia started therapy, she was suffering from serious
insomnia and talked vaguely of a strong distress that was making
it very difficult for her to work. We are going to show firstly how
her disorganized narrative style has a negative impact on her
treatment, and then the measures taken by her therapist to reor-
ganize it.

Disorganized Narrative Psychopathology

In her first session Lucia represented herself in a chaotic and


fragmented manner. She switched in confused and rapid succes-
sion from memories of her failed marriage to images of her
childhood when her father hit her, bit her and then lovingly
encouraged her in her studies, to sensations that her brothers
shut her out when she was an adolescent, and finally to a general
feeling that she has been treated unfairly in life. Dimaggio and

1
The name is fictitious.
Treatment of Disorganized Narratives 195

Semerari (2004) term this aspect of disorganization overproduc-


tion of narratives and deficit in hierarchization. Patients with this style
pile up one topic after another, open thousands of brackets that
they never close, and do not give a superordinate status to any of
the topics, which would allow one to see that all the others are
secondary and a sort of parenthesis to the core narrative theme.
Patient and therapist thus found themselves in chaos. Moreover,
Lucia had difficulty in depicting her emotional experience: she
was alexithymic (Taylor, Bagby, & Parker, 1997). Not being able
to identify any emotions in her discourse made it even more
difficult to give her topics a hierarchy.
Furthermore, Lucia displayed some serious dissociative signs:
she often smiled while recalling the saddest of memories. Dimaggio
and Semerari (2004) term this disorganization aspect basic inte-
gration deficit. It consists of an inconsistency between verbal con-
tent, arousal characteristics and expressive behavior. In fact, while
Lucia was talking about death, she smiled and looked relaxed.
Lastly, she sometimes came to sessions in a highly agitated con-
dition, which increased when she found it impossible to de-
scribe the causes of her suffering. Under the influence of this
mental state, she often made compelling requests for help from
the therapist.
We can hypothesize that the two aspects of Lucias disorga-
nized narrative that we have described (over-production and basic
integration deficit) are linked to a dysfunctional processing of
problematic emotions, which she tends to dissociate (Liotti, 1995)
when they becomes too intense. Lucia does not perceive certain
problematic emotional contents as being her own. It, therefore,
becomes impossible for her to include them in an intelligible
narrative plot. Dissociation and alexithymia are linked. Accord-
ing to Taylor and colleagues (1997), one of the features of alexithymia
is a difficulty in spotting links between causal events (both exter-
nal and internal) and the emotions one feels. Modestin, Ltscher,
and Erni (2002) note that this feature of alexithymia is corre-
lated with dissociation, that is, a difficulty in integrating thoughts,
emotions and events with each other in one overall state of con-
sciousness.
In Lucias case, in other words, dissociating her emotions
leaves her narrative without a cornerstone and her behavior ap-
pears unmotivated. Her ability to tell stories to others is impaired:
196 G. Salvatore et al.

without a clear emotional stimulus, which event should be re-


lated first?
Furthermore, alexithymia and dissociation assist in making
an unpleasant, undifferentiated arousal more intense. McLean
(1949) observed how an inability to regulate and give order to
emotional states through cognitive processes increased the in-
tensity of responses by the autonomic nervous system.

Impact on the Therapist

In the first session with Lucia the therapist felt intensely con-
fused and could see no links in what she was saying. There was
nothing in her narrative that might have provided him with an
indication about the line of action to be taken. At the same time,
he could see that her emotional suffering was very intense and
he felt pressurized by her frequent requests for help. Numerous
and contradictory scenarios passed through his mind: proposing
medication right away, prolonging the session until Lucia calmed
down, telephoning a relative of hers to ask him to take care of
her until the next session, and so on. Lucias disorganizition caused
the therapists thoughts to be disorganized too, together with a
sense of urgency and alarm. If he were to act under the influ-
ence of this chaotic state, he would do damage; Lucia would be
frightened in turn by his feeling of alarm, and her negative arousal
would become even more intense and disrupt her discourse even
more. When faced with such problems, a therapists main objec-
tives should, in our opinion, be to: (a) exercise inner discipline,
exit from the chaotic state and create a therapeutic relationship
based on sharing and validation of emotions; (b) reduce the
patients agitation and confusion; and (c) elicit the emergence
of the patients most significant emotions and integrate them
into his/her narratives.
We shall now present the general principles for treating dis-
organized narrative, using extracts from the first four sessions in
Lucias therapy as examples.

Inner Discipline and Construction of Sharing

Before any intervention, therapists need to extricate themselves


from this chaotic interpersonal cycle. To get out of problematic
Treatment of Disorganized Narratives 197

cycles, according to Safran and Segal (1990), therapists need to


exercise internal discipline, that is, modify their natural inclina-
tion towards acting, if this is driven by problematic emotions. In
Lucias case her therapist should modulate his inclination to pro-
pose interventions impulsively without any rationale and without
having understood what she is saying. To achieve this goal, he
starts by focusing his attention on his inner state and tries to pick
out the main elements in it, distinguishing between those that
come from his own personal history and experience and those
provoked directly by the patient. At a second stage he focuses on
the patients experience and asks himself if there are any aspects
in it that are similar or complementary to his own. In other
words, at this second stage the therapist looks internally for any
experience elements that he might be able to share with the
patient.
The result of this work is that the therapist perceived that he
shared with Lucia an inability to organize emotional experience
and to tell a coherent story to oneself and to other. He there-
fore avoided any impulsive actions with an ill-defined purpose
and told Lucia about his internal process, in order to make the
confusion question the central focus of his therapeutic discourse.
T: I realize that youre frightened and looking for urgent treatment,
and I too feel that you should be helped quickly, but Ive had the
impression that, in following you on all these topics, I was risking
getting confused. Everything youve said is important. What you ex-
perienced during your marriage, your relations with your parents,
your current illness, and your insomnia. The problem, however, is
that all these themes are piling up and getting mixed up together in
your mind at the same time and theres the risk they will confuse and
frighten you.
P: Yes, thats right.

The therapist included various dimensions in his interven-


tion. He shared in her problematic state of mind (I realize that
youre frightened and looking for urgent treatment, and I too feel that
you should be helped quickly), described how he himself mastered
his state (but Ive had the impression that, in following you on all
these topics, I was risking getting confused) and validated the con-
tents of Lucias discourse (Everything youve said is important). A
significant contribution to this validation also came from the list
the therapist offered of the various scenes related in a chaotic
198 G. Salvatore et al.

manner by her (What you experienced during your marriage, your


relations with your parents, your current illness, and your insomnia.).
This list was likely to give the patient the perception that he has
examined her experience attentively. Lastly, the intervention ended
with making the shared state a problem to solve with joint work
(The problem, however, is that all these themes are piling up and getting
mixed up together in your mind at the same time and theres the risk they
will confuse and frighten you.).
Let us summarize the overall purpose of such interventions:
to explicitly communicate to a patient that both the actors on
the therapeutic stage are experiencing the same chaotic state of
mind transforms something catastrophic into a problem of which
both are well aware and might attempt solving. The result is the
creation of a metaposition, from which the disorganization be-
comes an easily understood subject for their dialogue.
Moreover, from an interpersonal point of view, a therapists
ability to extricate him- or herself from a chaotic cognitive cycle,
avoid acting antitherapeutically and promote a sharing of experi-
ence, is a factor radically modifying a therapeutic relationship.
In fact, the atmosphere passes from one of confusion and alarm
to one of cooperation. Based on the previous intervention, the
therapist could now show Lucia the connection between the cha-
otic state and the increase in arousal, which had in turn a retro-
active and vicious effect on the chaotic state by reinforcing it.

T: I see. The fact is that when we feel confused about so many emotion-
ally important questions, we get frightened by that very confusion.
We get seized by an urgent need to understand and to clarify what is
happening, and in this way we risk increasing the confusion.
P: Thats exactly right: I get frightened.

There is already in this intervention a first attempt at con-


tainment and soothing. The patients reply shows that she is calmer
and shares in the therapists metaposition.
It is to be noted that the special feature of this intervention
is the fact that the therapist applies the very same understanding,
validation, and containment operations to the patient as he ap-
plied shortly before to himself. This endows the interventions
described with total authenticity from an emotional and rela-
tional point of view, an authenticity that is very likely to be noted
by the patient.
Treatment of Disorganized Narratives 199

Containment and Soothing:


Strategies for Mastering the Problem

A therapist should, in our opinion, at this stage also perform


specific active soothing operations and suggest strategies for the
mastering of the shared problematic state of mind

T: The first thing to do is to make it less urgent. Try as much as you can
to not enter this chaotic state. Dont worry: well manage to tackle all
the themes that you mentioned to me and that are piling up in your
head, but one at a time and when the time is right. Now we need to
conquer this confusion. One good way is to concentrate on some
outside activity, something that can take your mind off the urgency
and the sensation of confusion. We can think about your various
individual problems during your sessions, but now you must have it
clear in your mind that our prime common goal is precisely this
feeling of confusion of yours.

The fact of reducing the patients arousal and setting up a


shared metaposition prepares the ground for planning coping
strategies (One good way is to concentrate on some outside activity,
something that can take your mind off the urgency and the sensation
of confusion). Such strategies should be tried out in-between
sessions.
Every time that it was necessary in the successive stages, the
therapist went back to performing soothing of arousal and mas-
tery of the chaotic state. It is good if such operations become a
true and proper shared pool of knowledge, featuring a sort of
code language (in the next example chaotic states), to which
one can resort immediately whenever the problem surfaces. This
was very evident in this first extract from the third session.

T: How are things going with your chaotic states?


P: Lets say that Ive got my chaotic states fairly well under control.
T: How do you do it?
P: I make an effort not to think, even if its difficult. I try to concentrate
on things. Ive become aware of two fundamental things: Im feeling
very tired. A physical tiredness. I find it difficult to do things.
T: I wouldnt advise a holiday right now. Its better if you devote your-
self to things that keep you in touch with reality.
P: Yes, I agree, and Ive also tried to be at home when the cleaning lady
comes. Shes one of the few people who make me feel calm. Ive
become aware that people get on my nerves . . . .
200 G. Salvatore et al.

The therapist starts the session by giving a name to her dis-


organized state, a name that the patient remembers easily be-
cause it is a mutually agreed term that she has already used her-
self. She herself tells of how she has not only successfully adopted
a number of coping strategies agreed on at the end of their
previous encounter (I make an effort not to think. . . . I try to
concentrate on things), but has also conceived some new ones of
her own (Ive also tried to be at home when the cleaning lady comes.
Shes one of the few people that make me feel calm.). The emotional
atmosphere is relaxed and cooperative.

Emotional Validation

The sharing operations described above combine the therapists


own self-disclosure techniques with the validation techniques de-
scribed by Linehan (1993). The latter consist of telling patients
that there is something valid and understandable in their experi-
ence, even if it is dysfunctional. Sharing operations implicitly in-
volve this dimension. During the interventions described so far
the therapist has always maintained a validating stance. We would
however add another, more basic, level of validation consisting
of sincere encouragement and approval. If a therapist authenti-
cally feels these emotions, they can constitute an effective sup-
port to a patients conduct and stimulate a successful mastering
of the latters problematical emotions. In the following passage
also taken from the third sessionwe can see how the therapist
explicitly validated Lucia when she talked about the effort she
made at work in spite of her intense suffering.

P: No, because I feel responsible for it . . . I make a superhuman effort.


Of course, when I leave Im worn out . . . and then, . . . I feel
criticized, . . . in the sense that Ive always had, lets say, a bit of a
doctor-like attitude to my work and so maybe I spend more time
examining my patients than chatting with them . . . in fact I notice
that, in spite of this, I manage to keep up this attitude, even if I
ought to be a bit more . . . you know what I mean?
T: Yes, I know. Lets not be perfectionists now. It seems to me that
youve done very well to work in that state. This is okay. Its a good
sign that you manage to concentrate.
P: Yes and then, for example, this guy came and I thought we could do
other things for him, a therapy. I thought about where he could go.
Treatment of Disorganized Narratives 201

I could have been dealing with other things . . . This is a positive fact.
While I was finishing this, I felt satisfied.

At the beginning Lucia adopts a self-invalidating stance: she


reproaches herself because constantly thinking about her prob-
lems is very exhausting for her and makes it difficult for her to
maintain the efficiency standards she would like to in her work.
The therapists reply is in dialectical opposition to this stance. In
response to this emotional validation a scenario gets activated in
which Lucia acknowledges that she has done well and receives
gratification from this.
At the next stage, after regulating the patients chaotic states,
validation operations take on a specific and fundamental role in
stimulating an identification by the patient of her problematic
emotional nuclei.

Identification of Problematic Emotional Nuclei

We have seen how Lucias inability to organize her problematical


emotions causes dissociation. Once her chaotic state has been
regulated and her arousal diminished, the priority is then to make
a more detailed analysis of her states of mind. The next interven-
tion, which we term identification, is aimed at helping her to identify
her previously dissociated problematic states and integrate them
into her conscious discourse. At this stage, therefore, the thera-
pist is actively dealing with her alexithymia and is trying to build
a coherent narrative of her mental states out of somatically marked
mental images. We can see his attempts in the fourth session.

P: Listen, I had some big problems on Tuesday.


T: So youre not well. What problems do you have?
P: Apart from the fact that I didnt sleep in spite of my pill, I was even
more agitated than usual. And I also felt literally ill and, lets say,
physically a bit as well . . . this pain that gets to be a bit oppressive,
and that comes and goes all of a sudden and then reappears again.
As I was saying, I was burdened with this sensation. In the end I
couldnt wait for it to be daylight . . . It was with me, like . . . you
know when people are about to die, waiting to die, their last agony .
. . you know, like when youre confused . . . I cant express it more
rationally . . . Ive always thought there was something else, but which
we cant grasp, and maybe this thing I dont understand frightens
202 G. Salvatore et al.

me, beyond the fact that I was awake all night and couldnt wait for
the morning to come and . . .

From the start Lucias narrative concentrates on a sole nar-


rative scenario, but the emotion behind the narrative is unclear
and there is only an undifferentiated arousal. Her representation
of death remains indistinct and unspecific. The therapist makes
the following intervention.

T: But what was going through your mind? What images? What thoughts?
That you were dying . . . Could you see yourself in your death-bed?
P: No, it seemed as if . . . That wasnt what I was thinking. They werent
images in that sense. But I had that sensation, without it being real,
that people who are about to die get, when they feel alone . . . . I
dont believe someone about to die realizes that . . . . youre looking
for something, arent you? And then, I dont know, I want to look for
my father, perhaps . . .
T: How do you mean?
P: Images ( crying as she speaks), this one here!
T: Were you thinking of your father? Calling him?
P: Not calling but it can certainly happen that I pick up a photograph
that way were togetherand perhaps put it under my pillow. . . .
However in the past Id never done this.
T: And why? It soothed you?
P: Yes, but it seems that at the same time theres something . . . I try to
seek out an affection, something affectively important for me.

The therapists questions tried to throw light on the emo-


tions inside Lucias experience, contained in images and frag-
ments of scenes (But what was going through your mind? What
images? What thoughts? That you were dying . . . Could you see yourself
in your death-bed?). This intervention made Lucias discourse more
coherent, so that she described her experience better (That wasnt
what I was thinking. They werent images in that sense. But I had that
sensation, without it being real, that people who are about to die get,
when they feel alone . . . . ). This led to the emergence of emo-
tionally intense images: Lucia cried as she thinks of her father.
The emotion that emerged attracted other mental images consis-
tent with it. A clear story, centered on a sense of loss and the
need for someone to looked after her, took shape (it can cer-
tainly happen that I pick up a photographthat way were together
and perhaps put it under my pillow;; I try to seek out an affection).
Treatment of Disorganized Narratives 203

As can be seen, these identification operations are possible


because there is no longer the previous chaotic and frightening
atmosphere. In other cases identification operations take the form
of a true and proper emotional labeling, with a therapist helping
a patient to recognize and name his/her problematical experi-
ences. There is an example of such an operation in the third
session. Lucia had just mentioned vaguely about how agitated
she felt her life was, but then she changed the subject:

P: Ive put a bit of a question mark over the relationship Ive got with
this friend . . . who Ive known for 10 years, and I stopped for a
second to ask myself how I should act towards her because I feel just
a bit oppressed . . . shes had some big disappointments and Ive
tried to be at her side, but lately shes been feeling neglected, as if
my attention towards her hadnt been attentive enough and this . . .
was difficult for me because I too . . . I dont like feeling oppressed.
I imagine that youve perhaps realized this . . . Ive realized it myself
too! (Laughs).
T: But do you have the sensation . . . how can I say? That youre taking
some urgent and important decisions? That you have to do some-
thing important in your life?
P: It seems as if I need to reacquire something in my life.

The therapist was trying to lead Lucia to her main emotion.


As the session continued, he tried to identify this emotion, which
became better defined as a sense of urgency.

T: Because you talk about these things as if you were in a hurry. As if


you needed to do something . . .
P: Yes, youre right. This way I have of being seized by thoughts and
things too. Its because on the one hand I want to get this thing off
my back, because afterwards Ive got others to do, but at the same
time I need to clarify things and I cant!
T: Its as if you needed to make some fundamental life choices and in a
hurry too.
P: Yes . . .
T: But its not clear how . . . if you want to get married, change your job
...
P: No, exactly, my work. I certainly need to take some decisions . . .
T: Well, these are normal choices. Do you have a subjective sense of
urgency!?
P: Yes, because, you know what? Its that Im used mentally to having to
do everything quickly, do you see? Even if theres lots to do . . . This
204 G. Salvatore et al.

arises for sure from the fact that my parents instilled it in me a bit
from when I was a little girl, when I was born . . . They were always
instilling it in me . . . that Id better get straight down to doing things
because if they died who would there be to look after me.
T: And so they hurried you up right from the start. Is your mother still
alive?
P: Yes . . . Ive always done what I had to do like this, and in a state of
distress too.

The therapists interventions helped Lucia to see how she


was driven by urgency and distress when she did things. These
were terms proposed by the therapist that she then used herself.
After focusing on emotions, Lucia almost automatically linked
them to autobiographical memories (This arises for sure from the
fact that my parents instilled it in me a bit from when I was a little girl;
Ive always done what I had to do like this, and in a state of distress
too). Her story had now become clearer and more integrated in
her overall self-narrative. In the last extract one can see how
Lucia had reached an observing metaposition and gained the
ability to tell a coherent story on her own.

P: Well, my chaotic states. Look, on Saturday night I couldnt sleep.


That is, the whole night awake, but I read a bit and I was quite calm.
Then, in the morning, my sister called me. She wanted me to go to
lunch with her. And so I got this problem of whether to say no, I
mean of saying that I didnt want to go, and this made me . . .
agitated and then . . . I burst into tears, because I remembered my
father dying, the night he died, I mean . . . then I left and thats all.

The patient resorts to the code language she shares with the
therapist to identify her chaotic state. She shows that she is able
to master it successfully, even although it causes her suffering.
She is also capable of seeing the link between her agitation and
the events triggering it (I remembered my father dying . . .), and of
putting together orderly series of emotionally laden events in a
flow of consciousness.

Conclusions

We have been analyzing a patient whose narrative was both frag-


mented (facial expression not consistent with the theme of her
discourse and absence of emotional experience) and dissociated
(some aspects of her story not surfacing in consciousness). Such
Treatment of Disorganized Narratives 205

a disorganization presents problems for psychotherapy; it is an


indicator of a serious emotional disorder preventing patients from
cognitively working trough their problematic emotions by insert-
ing them into a narrative plot with which it is possible to see the
links between the emotions and the eliciting events. Furthermore,
disorganized narrative exposes therapists to the risk of falling
into problematic interpersonal cycles, in which they experience
states of inner chaos and impotence that render their interven-
tions potentially antitherapeutic. In the case we have portrayed,
the therapist was successful in helping Lucia to put together a
better organized, clear and coherent story. At the onset of therapy,
her stories lacked appropriate emotions; she would laugh as she
talked about death. After just a few sessions she cried when she
talked about death and looked for consolation. The effectiveness
of the treatment was confirmed by the improvement in her symptoms
too; already after just a few sessions there had been a reduction
in Lucias agitation and insomnia.
On the basis of our session extract analysis, it is possible to
summarize the interventions a therapist should make to render a
patients discourse more organized, with a view to being able to
propose these interventions as an easily applicable and empiri-
cally verifiable model for the treatment of such disorders. First of
all, it is understandable that therapists feel a sense of confusion
and frightened urgency when they listen to a chaotic narrative.
The first operations they should perform are inner discipline
ones. These get carried out in two stages: in the first therapists
should try to perceive and describe to themselves the elements
making up their own emotional states when they are with their
patient; in the second stage they should look for those aspects of
their emotional experience that they share with the patient. These
initial operations should help a therapist avoid performing dis-
regulated interventions, that is, harmful acting-out induced by
the disorganization. Once they have achieved these goals, the
next intervention by therapists should be to declare that they
and the patient have a common problem that they can solve in
cooperation. This encourages the acquisition of a metaposition
regarding the problem and fosters the passage of the therapeutic
relationship from chaos to collaboration. With an atmosphere
like this, a therapist can expect that direct interventions aimed at
soothing a patient will be successful. The sharing of a problematic
206 G. Salvatore et al.

state in a calm and cooperative relational atmosphere is a pre-


condition for suggesting and agreeing upon the strategies for
the mastering of that same problem to be adopted between one
session and the next. We lay great importance on emotional vali-
dation during this delicate stage of a treatment. The therapist is
continuously stressing the aspects in the patients problematic
experiences that they have in common, but also supplies some
explicit reinforcements to the adaptive aspects of his behavior.
The operations described so far serve, in our opinion, to lay the
foundations for helping the patient to identify her previously
dissociated emotions, which were making her experience frag-
mented.
The evolution of this case, therefore, indicates that the type
of intervention we are proposing is a good candidate for being
effective in other cases where there are similar alterations to a
patients narrative. The main limitation to our work is its limited
generalizability, typical of single cases studies. On this point, other
studies of individual cases, with a longitudinal analysis of even an
entire therapy course and the addition of the opinion of some
independent raters, could increase the scientific value of our ob-
servations.

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