SUPERVISION IN THE PSYCHOTHERAPY
OF SCHIZOPHRENIA: AWARENESS OF AND MUTUAL
REFLECTION UPON FRAGMENTATION
Paul H. Lysaker
, Kelly D. Buck
, Michelle L. Pattison
Rhianna E. Beasley
, Jaclyn D. Hillis
and Jay A. Hamm
Historical and newly emerging models of schizophrenia suggest it is a disorder characterized by
the fragmentation of the experience of the self and the world, leading to the interruption of how
a unique life is unfolding in the world. It has been proposed that psychotherapy might therefore
promote recovery by facilitating the development of a greater ability to integrate information
about the self and others. In this paper we explore how the supervision of a metacognitively-
oriented psychotherapy can assist therapists to experience and conceptualize fragmentation
within sessions, join patients in the gradual process of making sense of their psychiatric
problems and life challenges, and ultimately envision and achieve recovery. Common chal-
lenges and responses within supervision are described and discussed.
KEY WORDS: schizophrenia; psychosis; supervision; psychotherapy; metacognition;
Paul H. Lysaker, PhD, Richard L Roudebush VA Medical Center, Indianapolis IN; Department
of Psychiatry, Indiana University School of Medicine, Indianapolis IN, USA.
Kelly D. Buck, PMHCNS-BC, Richard L Roudebush VA Medical Center, Indianapolis IN.
Michelle L. Pattison, MA, School of Psychological Sciences, University of Indianapolis,
Rhianna E. Beasley, MA, School of Psychological Sciences, University of Indianapolis,
Jaclyn D. Hillis, PsyD, Chillicothe VA Medical Center, Chillicothe OH.
Jay A. Hamm, PsyD, Midtown Community Mental Health, Indianapolis IN.
Address correspondence to: Paul H. Lysaker, PhD, Richard Roudebush VA Medical Center
116a, 1481 West 10
St., Indianapolis IN 46202, USA. Email: firstname.lastname@example.org
The American Journal of Psychoanalysis, 2019, 79, (284–303)
2019 Association for the Advancement of Psychoanalysis 0002-9548/19
The psychiatric conditions now referred to as schizophrenia spectrum
disorders have often been suggested to reﬂect the kinds of processes which
are not accessible or responsive to psychosocial interventions. For example,
in the view of Kraepelin (1919) and others (Falkai et al,2015), these
conditions reﬂect a biological disturbance, most likely metabolic in nature.
These basic disturbances then lead to the loss of volition, drive, and affect
(Noll, 2011) which would not be amenable to psychosocial interventions
In contrast to Kraepelinean and neo-Kraepelinean views, there are other
views which comprehensively describe the challenges of schizophrenia but
link it with phenomena which could be addressed by psychosocial
treatments including psychotherapy. Most popular among these are the
views of Bleuler (1911) and others (Hamm et al,2017) which suggest that
schizophrenia develops around the fragmentation of self-experience
(Katschnig, 2016). Rather than involving a direct pathway from biological
disturbance to psychosocial disturbance, Bleuler proposed that schizophre-
nia reﬂects a process in which patients’ lives are interrupted by the
fragmentation of previously integrated psychological processes (Maatz et al,
2015). Working with Jung, Bleuler (1911) concretely proposed that in the
conditions he labeled the schizophrenias, persons experience diminished
abilities to coherently link ideas, emotional experience and desires together.
He referred to these respectively as disturbances in associations, affects and
ambivalence. As a result of each of these losses Bleuler observed that there
necessarily followed the collapse of basic goal-directed activity and
connection with the world, which he referred to as autism.
Historically it is important to note that Bleuler was inﬂuenced by Freud
and his models of psychosis, which also emphasized phenomena which
could hypothetically be the focus of psychosocial treatment. These included
the unbinding of thoughts and affect as well as gross withdrawal from the
world (Freud, 1914,1915). Indeed, following Freud’s writing, psychoana-
lytic work exploring the issue of fragmentation within schizophrenia
continued. Some work, for example, has sought to pinpoint the loss of a
larger sense of the self and others as occurring at the level of boundary
disturbances between objects in the world (Federn, 1926) or during the
process of symbolization (Arieti, 1955). In his discussion of narcissism as
fragmentation, Kohut (1971) described psychosis as an even more profound
collapse of the connection between individual bodily and mental activities,
one which was so extreme that it rendered mental experiences ‘‘pre-
psychological’’ (p. 30). Bion (1959) and Winnicott (1963) have explored
these ideas, examining how fragmentation may occur as a means of
protecting a rudimentary sense of self that is threatened by both its own
experiences of the world and the experience of what the world provokes
SUPERVISION IN THE PSYCHOTHERAPY OF SCHIZOPHRENIA 285
within it. Others have proposed that internal experience may become
fragmented as a result of defective processing of experiences, including
those with early caretakers (Wexler, 1971). More recent work (Gurevich,
2014) reveals continued interest in fragmentation, including the role of
external trauma in its emergence.
Seeking to unify psychoanalytic theory about the fragmentation of self-
experience and schizophrenia, Grotstein (1977) has proposed that there
may be different pathways to fragmentation. Speciﬁcally, psychosis is
suggested to emerge as a result of the lack of stimulus barrier or a
heightened sensitivity to stimulus. For Grotstein, either process can make
persons vulnerable to experiences, wishes and impulses which threaten the
existence of the self, and the only recourse is to derail thought processes in
general such that persons are no longer able to form integrated ideas about
themselves which might be understood by others. Following up on this,
Ogden (1980) has proposed an even broader model in which fragmentation
creates a state of non-being in which tensions exist as to whether any sense
or meaning at all will be assigned to experience. Acknowledging the
possibility that fragmentation could be primarily a result of any of a number
of factors, Frosch (1983) has noted how nevertheless, the end result of
fragmentation is the experience of the self as tenuous and on the edge of
destruction, and hence is both a source of dysfunction as well as pain.
As noted above, for the ﬁeld of psychotherapy, these theoretical issues
are of core importance since they suggest a potential role for psychotherapy.
If fragmentation in self-experience is a central aspect of schizophrenia, then
naturally questions arise regarding whether and how psychotherapy might
treat the experience of fragmentation. Certainly, if a form of psychotherapy
could treat fragmentation directly, then it would have the potential to help
persons with schizophrenia regain the ability to coherently link thoughts
together, make sense of affects, sort out wishes and needs, and ultimately,
decide how to ﬁnd a way to a satisfying life. This is consistent with a long
history of psychodynamic psychotherapy of schizophrenia which can be
seen as seeking to promote the coherence of internalized representations of
self and others, and their relationships to one another (Searles, 1965).
One response to these questions has been the proposal by metacogni-
tively-oriented researchers that psychotherapy might help resolve fragmen-
tation by addressing how persons notice discrete pieces of information, how
they integrate or bind those pieces of information together to promote a
sense of self and others, and ultimately, how they then use that available
information to understand and address emergent challenges in life (Lysaker
and Klion, 2017; Lysaker et al,2019). This work has used the term
metacognition to refer to a spectrum of activities which enable persons to
have a cohesive sense of self and others available within the ﬂow of life
286 LYSAKER, BUCK, PATTISON, BEASLEY, HILLIS AND HAMM
(Lysaker et al,2018a,b) and the concept of deﬁcits in metacognitive capacity
to operationalize the processes which characterize fragmentation. This work
has relied on a new methodology to document the presence and inﬂuence of
the fragmentation experience in schizophrenia (Hamm and Lysaker, 2016;
Lysaker et al,2018b), to conceptualize the disruption in metacognitive
capacity as a treatment target, and at a ﬁner level of analysis, to use
interventions that directly promote the integration of complex ideas about the
self, others, and one’s larger community (Lysaker et al,2018). This form of
psychotherapy, Metacognitive Reﬂection and Insight Therapy (MERIT)
(Lysaker and Klion, 2017), has shown initial promise promoting integration
and wellness in two randomized trials (de Jong et al,2018; Vohs and
Leonhardt et al,2018) two open trials (Bargenquast and Sweitzer, 2014;de
Jong et al,2016), two qualitative studies (de Jong et al,2019; Lysaker et al,
2015), and multiple detailed case studies (c.f. Hamm and Lysaker, 2018).
One challenge to the implementation of MERIT and related practices that
focus on integration in psychotherapy concerns the need for therapists to
shift their focus away from content and instead to how persons are
assembling information about themselves and others (Hamm et al,2016). In
particular, this may require activities that run counter to current psy-
chotherapy training trends and pose challenges for which many psy-
chotherapists may be unprepared. In this paper, we will examine two
speciﬁc challenges: awareness of the experience of fragmentation and the
development of a mutual reﬂection upon fragmentation as a means to
address it. While there is clear overlap between these challenges, we think
of the ﬁrst as more pertaining to awareness of fragmentation itself and the
second to the processes which lead to its resolution. For each of these
challenges, we will describe the dilemmas posed for the therapist and the
psychotherapy, and then focus on supervisory responses that may assist
psychotherapists in effectively responding to and treating fragmentation in
adults diagnosed with schizophrenia. Finally, we will discuss broader
implications of these issues that tend to arise during the supervision of
psychotherapy and other services that address recovery from complex
mental health conditions.
Of note, in discussing psychotherapy supervision we will be focused on
our experiences and reﬂections about the supervision of MERIT. However,
we suggest that these supervisory processes are applicable to a broader class
of integrative, humanistic and psychodynamic psychotherapies which may
ultimately promote health by helping persons make sense of their
experiences and challenges and decide upon an adaptive course of action.
We are also focusing explicitly on recovery as an outcome from
schizophrenia. As reviewed elsewhere (Leonhardt et al,2017), the recovery
model stresses that schizophrenia is not a condition with a uniform outcome
SUPERVISION IN THE PSYCHOTHERAPY OF SCHIZOPHRENIA 287
involving progressive deterioration. Instead, the attainment of wellness in a
manner that is personally meaningful and acceptable to patients is a
reachable outcome and should be the goal of treatment.
TWO CHALLENGES FOR THERAPISTS AND SUPERVISORS WHEN RESPONDING
TO FRAGMENTATION EXPERIENCED BY ADULTS DIAGNOSED
WITH SCHIZOPHRENIA SPECTRUM DISORDERS
Approaching fragmentation as a phenomenon to be perceived and understood
The ﬁrst challenge we propose that therapists and supervisors face when
working with people who experience fragmentation is the need for the
therapist to conceptualize and recognize the experience of that fragmen-
tation itself. Patients do not generally express to the therapist that their
experience is fragmented. They do not directly report that their thoughts,
emotions, and basic needs lack integration. Fragmentation is not something
similar to a medical symptom which appeared one day. Instead, fragmen-
tation is something for the therapist and patient to jointly perceive as
patients talk about their lives.
The fragmentation of a sense of self in schizophrenia has been described
using many different metaphors, including Kraepelin’s orchestra without a
conductor. From a metacognitive view, however, we have recently suggested
that rather than the loss of a conductor ‘‘directing a scored ensemble,’’
fragmentation represents the absence of ‘‘an arranger, who sometimes
improvisationally, sometimes habitually, locates possibilities in parts of what
metacognition accesses…intersubjectively framed experiences of self-world
interactions’’ (Lysaker et al,2018b, p. 166). Concretely, this can appear in
many forms including monological, barren, or cacophonous presentations of
the patient’s experience, or any combination of those presentations.
Recognition of fragmentation in each of these states represents awareness
of discrete and often relatively simple atomistic aspects of experience that are
not connected to other aspects of experience in a meaningful manner. In a
monological presentation, for example, a person might be aware of a single
theme of experience, such as feeling persecuted or unappreciated, but fail to
meaningfully integrate other aspects of experiences to form a complex and
cohesive understanding of that single theme. In a barren presentation, for
example, there may be only small pieces of experience, such as an awareness
of having no thoughts, which—like a monological presentation—is not
integrated into any larger sense of self or others.
The natural challenge here for therapists is to be able to see the absence
of integration as patients describe their experience. To do so, it would seem
288 LYSAKER, BUCK, PATTISON, BEASLEY, HILLIS AND HAMM
that therapists must have the awareness of their own integration of
experience, something which generally happens automatically and
instantly, and then imagine what would happen if they could not integrate
information. In supervision, we have used the following illustration to help
therapists grasp the idea of automatic integration and what would happen if
it failed. In this illustration we ask the therapist to imagine themselves or
someone else attending a lecture. A person with intact metacognitive
capacity may realize and simultaneously understand their experiences of
incessant foot tapping, warmth in their face, preoccupation with their
grocery list, and a wish to leave the room as reﬂecting something larger,
such as being angry with something said in the lecture. There might even be
a broader, more complex thought such as a similarity between being angry
about this issue during the lecture and other things that anger the person in
other situations, perhaps leading to a realization that their anger is
exaggerated and should not be expressed.
With this example we hope in supervision to help the therapist realize
how instantly a broader and nuanced sense of oneself appears and how it
informs action. The next step is to think about what happens if a person
experiences incessant foot tapping, warmth in their face, preoccupation
with their grocery list, and a wish to leave the room but is unable to see how
those experiences are connected, something that may parallel Bleuler’s
original ideas about the fragmentation of experience. Commonly, therapists
can then imagine how they, the therapist, might feel disoriented, for
example, if they could notice but not understand their foot tapping, warmth
in their face, and preoccupation with seemingly irrelevant thoughts, thereby
forming a more embodied understanding of fragmentation.
Returning to the task of the therapist to accurately perceive the degree to
which patients experience fragmentation, we are in the broadest sense
calling for supervision to support therapists in making accurate assessments.
At issue in supervision is whether the therapist has overestimated or
underestimated the degree of integration of which the patient is capable,
and therefore, is not accurately perceiving the patient’s experience of
This has requirements that go beyond didactic training in assessment,
however. It requires ongoing reﬂection within supervision about biases and
reactions that can affect assessment and understanding of fragmentation.
Foremost, supervision must implicitly and explicitly assist therapists to think
about their own metacognitive processes as they think about the patient.
How have they integrated the information the patient has shared, and have
they formed an understanding of the patient’s experience of themselves and
others? Then, how well does that picture match the patient’s behavior?
Thus, supervision provides a kind of parallel process (McNeill and Worthen,
SUPERVISION IN THE PSYCHOTHERAPY OF SCHIZOPHRENIA 289
1989; Mothersole, 1999) in which there is ongoing reﬂection about
At the risk of creating a false dichotomy, we have observed that when
supervision takes on the question of how the therapist is integrating
information, we ﬁnd therapists are likely facing two different types of
problematic responses. In the ﬁrst problematic response, the therapist, as a
matter of habit, has overestimated patients’ degree of integration because he
or she has automatically ﬁlled in information or perceived integration when
it was not happening within the patient. This is consistent with a well-
documented ﬁnding from visual perception research that persons ﬁll in
missing information when presented with images of incomplete objects
(Gregory, 1977). In a similar manner, therapists may automatically sense
that patients are having more integrated experiences because they, the
therapist, have connected the fragments together and possibly have done so
without even being aware of it.
To illustrate this issue, consider that the patient is the person at the
lecture with incessant foot tapping, warmth in their face, preoccupation
with their grocery list, and a wish to leave the room. A therapist may
assume that the patient can readily see he or she was angry because the
therapist can see these signals in his or her life and in the lives of others.
The therapist may then repeatedly ask the patient for emotions he or she
felt and suggest to the patient that he or she was angry until the patient
agrees with them. The idea that the patient was angry and aware of it
might relieve therapist anxiety that can often emerge when experiencing
fragmentation. In other words, the call for such agreement from the patient
might stem from the therapist’s wish to connect the fragments to ward off
his or her own discomfort when facing uncertainty and novel experiences.
Thus, that reduction in anxiety could be perceived by the therapist as
direct evidence of the correctness of their view that the patient was indeed
aware of their anger, which in turn could help restore the therapist’s sense
of personal adequacy. Another therapist might interpret the lack of
expressed emotion itself as a reﬂection of a lack of motivation and
similarly grossly fail to appreciate how the patient’s inability to piece
together aspects of their experiences into more complex ideas may be
contributing to the absence of behaviors. This assumption might relate to
previously held ideas that a barren state or disorganized thoughts are
symptoms that should be targeted ﬁrst, rather than seeing these experi-
ences as likely reﬂecting fragmentation of psychological processes that can
be understood as potentially meaningful and addressed by promoting
A second problematic response stems not from automatically ﬁlling in
information and missing fragmentation, but from therapists ﬁnding it painful
290 LYSAKER, BUCK, PATTISON, BEASLEY, HILLIS AND HAMM
or disorienting to accurately perceive fragmentation. It may be painful for
therapists to see the suffering inherent in fragmentation. Seeing a patient in
such great pain may also leave the therapist feeling powerless and
vulnerable. The fragmentation of the patient may also be disorienting to
the therapist, making them feel as if their own metacognitive capacities are
failing. These difﬁculties may be particularly pronounced for new therapists
who are striving to master newfound psychotherapy skills, yearning for
structure within psychotherapy to alleviate anxiety, or struggling with their
own feelings of inadequacy and confusion. All of these may motivate the
therapist to see more integration than exists to escape from their own
As an illustration of this, continuing with the example of the patient
talking about what happened at the lecture, perhaps the initial experience
of the patient’s fragmentation was disorienting for the therapist. Sitting
with the patient who couldn’t see the same meaning structures as the
therapist did may have led to the fragmentation of the therapist’s own
experience. Concretely, facing the patient who could not link together
experiences into a sense of self and others, the therapist may have felt
confused about what was being asked of him or her, resulting in a feeling
of being inadequate which could be alleviated if the patient was seen as
Importantly, an entirely different and equally problematic solution may
also occur. Therapists who react adversely to patient fragmentation may ﬁnd
it a relief instead to assume that there is no meaningful mental activity going
on and hence no suffering. An example of this could be the therapist who
equates fragmentation with cognitive impairments and so treats their
patients as unable to beneﬁt from a reﬂective form of psychotherapy. In our
experience, the therapist in this scenario may often postpone psychotherapy
or suggest neurocognitive testing to establish whether the patient is
‘‘appropriate’’ for psychotherapy. At the phenomenological level, the
therapist here may, in error, interpret fragmentation as the absence of
In response to these problematic responses—the false perception of
integration or negative reactions to perceived fragmentation—the supervi-
sion process is likely to be the same. There is a need to help therapists see
the fragments of the patient’s experience, suspend any automatic tendency
or wish to connect the fragments, and explore reactions to patients’
fragmented experience of themselves. In taped supervision, this could
involve identifying tracts of texts which express fragments of experience that
can be ﬁrst considered on their own and then later seen as connected with
some degree of integration. The timing and content of therapist interven-
tions can also be considered as a potential reﬂection of their responses to
SUPERVISION IN THE PSYCHOTHERAPY OF SCHIZOPHRENIA 291
fragmentation. For example, trying to cheer a patient up or smooth over a
disagreement could be seen as a reﬂection of the therapist’s discomfort with
fragmentation, as could a therapist avoiding affect-laden topics.
Helping therapists both to correctly perceive fragmentation and to
understand how they came to mistake fragmentation for either something
more integrated or as irrelevant experience may call for normalization of
therapists’ feelings of fragmentation, confusion, or anxiety. It may require
supervisors to disclose their own experiences of fragmentation and
discomfort with uncertainty. They may frame for therapists how they have
developed ideas about the ‘‘short cuts’’ they take to understanding others
and personally relevant clues or hints that come up when they are taking
those short cuts, spurring therapists to do the same.
In our experience, this process often involves several twists. First,
therapists may feel they are ‘‘breaking’’ rules that preclude persons in most
social situations from perceiving undesirable pieces of one another. Many
therapists trained contemporaneously may have felt urged in previous
training to suspend judgments about others and so feel ethically prohibited
from knowing aspects or fragments of patients (or themselves) which are
not prosocial and might be perceived as selﬁsh, aggressive, or egocentric.
For example, a therapist may feel it is wrong to notice the fragments of
experience related to sexuality and rage in the patient who deny these
feelings and instead parrots material from psychoeducation about their
need for medication. Other therapists may also have had previous training
and professional experience in which their own anxiety and pain was seen
as a sign of ill health and something to be denied as quickly as possible. In
previous unfortunate experiences, therapists’ awareness of their anxiety or
anger in the face of a patient may have been dealt with in supervision not
as an important clue about the therapy in question but as a treatment need
of the therapist. It may thus be necessary in supervision to acknowledge
how different and challenging this approach may be for the therapist. It
may be essential for therapist frustration and anger with the supervisor for
their attention to these details to be acknowledged, again in a matter of
parallel processes that promote reﬂectivity. As long noted by others
(Searles, 1965), supervisors might need to be aware of their own
competitiveness with therapists, as well as their needs for certainty and
therapist approval. Thus, in another parallel process supervisors may need
to be aware of these reactions on their part and move beyond those to
allow the therapist to have their own unique and possibly surprising
reactions to the supervisor.
292 LYSAKER, BUCK, PATTISON, BEASLEY, HILLIS AND HAMM
Understanding that fragmentation is resolved as meaning is jointly made
While the ﬁrst challenge we identiﬁed for therapists pertained to the need to
perceive fragmentation itself, the second concerns the need to understand
how fragmentation can be resolved in psychotherapy, which is only through
joint reﬂection. Considered as a fundamental aspect of human conscious-
ness, all of us need the presence or potential presence of another mind to
piece together experience and decide what it means (Hasson-Ohayon et al,
2017). The broader senses we evolve of ourselves that move beyond
speciﬁc experiences are dialogical. Put more simply, meaning making is
intersubjective (Stern, 1985; Yerushalmi, 2012). Even when we draw private
conclusions about ourselves or others, those ideas are always created with
someone to whom they might be addressed, whether that person is a real
person, someone we remember, or someone we imagine we might
encounter in the future. This is to say that the way we connect what we
experience into larger meaningful phenomena are neither things we do in
isolation nor are they the result of conclusions which others supply us.
One implication of this for therapists who have come to perceive
patients’ fragmentation is that integration can only be promoted by joining
with patients and thinking together about the experience of those fragments
(Buck et al,2015). It is here where we see the second general issue for
supervision. At both an epistemic and ontological level, how are therapists
inclined to respond to their awareness of patients’ fragmentation? At the
therapist level, how does the therapist choose immediately and automat-
ically to promote integration in therapy and develop a process of joint
reﬂection with patients about their experience?
The therapist’s task is to think with patients about the fragments of their
experience and how the patient is or is not integrating those experiences.
This requires several activities including that therapists remain focused on
the task of joint integration and do not assume the task of primarily coming
up with solutions on their own and then sharing them, no matter how clever
those solutions may appear. Thoughts and experiences should be ﬂuidly
shared and considered in a way that matches patients’ capacities for
integration or metacognition (Lysaker et al,2011). The therapist and
supervisor may conceptualize the patient’s dilemmas by analogy as similar
to those of the calculus student for whom the problem is that they don’t
know how to solve the speciﬁc calculus problem, not that they simply don’t
know the answer to a speciﬁc problem. Following that framing, the therapist
may need to help the patient do more than just ﬁnd the right answer to the
speciﬁc problem. Patients facing fragmentation need someone to join them
and begin by helping them reﬂect upon the pieces of their experiences, and
SUPERVISION IN THE PSYCHOTHERAPY OF SCHIZOPHRENIA 293
then explore how they might slowly integrate those pieces. For example, in
the illustration of the patient attending the lecture, the MERIT therapist
would try to understand with the patient the many different fragments the
patient was experiencing and to jointly know that the patient experiences
many different things which they struggle to see as related. This is consistent
with the view that can be found in person-centered approaches that frame
recovery from serious mental illness as a matter of ‘‘co-construction’’
When this is successful, therapists should be able to name different
fragments expressed by patients without offering complex connections
between them that could exceed patients’ metacognitive capacities.
Supervision then can support this in several ways. For one, therapists may
think through and better see the distinctions between different fragments
that have emerged in a given session. With those fragments successfully
separated in their mind, they might in supervision hypothesize different
ways that those fragments might be connected. In the manner of parallel
process, the supervisor and therapist might jointly think about what the
fragments could mean in terms of their larger relationships to one another.
For example, consider the patient who discussed (over the course of one
session) abandonment by a parent, the disappearance of a sister, an
aggressive verbal attack on a neighbor, recent drug use, gross lack of
activity, eating a large lunch, and then wanting to reduce frequency of
sessions. Supervision might support reﬂection about these individually but
then think about how these fragments might come to be assembled by the
patient and therapist later as reﬂections of a larger experience of the
tenuousness of relationships, confusion about interpersonal connections,
and potentially that the end of every session is painful for the patient (e.g., it
is something good that abruptly ends, leaving the patient bereft).
Beyond the consideration of the fragments themselves which patients
present, supervision can also explore therapists’ experiences of encounter-
ing fragments and not connecting them. There may indeed be common
experiences here between therapists. As is well documented, when human
beings experience the fragmentation of another, we may readily fear our
own fragmentation or the loss of our ability to integrate information (Searles,
1965). Supervision can support therapists here by disclosing supervisors’
similar reactions. Naming and normalizing these experiences can further
diffuse their power to create disruptive levels of anxiety in the therapist.
When experiencing fragments that the therapist does know how to connect
to one another, therapists may also not so much react negatively but be
willing to doubt themselves or feel confused.
For example, when aggressive aspects of the patient emerge, some
therapists may ﬁnd them aversive when they realize that if they met those
294 LYSAKER, BUCK, PATTISON, BEASLEY, HILLIS AND HAMM
aspects in other people in their lives, they would hold them in disdain.
Following the same pattern, when encountering fearful aspects of the self of
a patient who genuinely ﬁnds safety in inactivity and withdrawal, other
therapists may again be uncomfortable when they realize they would avoid
someone who acted this way in their own lives. They might also become
fearful the patient will always remain stuck without clear goals to become
healthier like people they have known, and again this may lead them to feel
signiﬁcant self-doubt and hopelessness. Thus, supervision can support
therapists by helping them identify themes they respond strongly to, see that
patients are composed of many facets or fragments of self-experience, and
expect a dynamic interplay among them which may culminate in
movements towards health.
When therapists are not joining patients and exploring their experiences
in ways that match patients’ metacognitive capacity, this can be apparent
from therapists who either cannot name distinct fragments or who ‘‘chunk’’
sessions in larger themes, and hence, see only a larger incoherent whole
(i.e., not its constituent parts unrelated as they may be). In other words, it
should be apparent in supervision that the therapist is not considering the
patients’ fragments of self-experience as potentially independent of one
another. It can also be reﬂected in language in which therapists acknowl-
edge that they are to ‘‘trying to get’’ the patient to do or think something, or
prescribing them activities which they believe will relieve fragmentation.
Those activities could be sensible and well-meaning when considered on
their own. For example, a therapist who is compelled to ﬁx the fragmen-
tation might refer the patient to an expressive therapy class, mindfulness, or
Here supervision may take any number of routes depending on the extent
to which this is a reaction to speciﬁc content or whether it reﬂects a larger
epistemic stance on the part of the therapist. In beginning therapists who
have a basic stance that impedes joining and reﬂecting upon fragments of
experience, this can reﬂect a need to ‘‘ﬁx’’ patients before getting to know
them. This goal of ﬁxing may be a reﬂection of a professional identity, but it
may also be an aspect of stigmatizing views of patients in which persons
with psychotic disorders are mistakenly seen as unable to manage their own
lives and require the kind of benevolent care afforded to persons with severe
neurocognitive disorders (Buck and Lysaker, 2010). As noted above but also
described elsewhere (Hamm et al,2016), supervision can help therapists
realize that their basic assumptions and embodied responses to fragmen-
tation are inaccurate or unhelpful. For instance, it may reveal stances taken
by the therapist in which they are most comfortable when telling patients
about reality, encouraging healthy behavior, advocating for patients, or
soothing patients’ discomfort. Supervision may therefore have to directly
SUPERVISION IN THE PSYCHOTHERAPY OF SCHIZOPHRENIA 295
address both unhelpful and stigmatizing stances before fragmentation can
be meaningfully discussed. This could include frank discussion about
stigma as well as the pressures that come from our institutions and traditions
that make it easy to take on an expert or caring role, both of which are easily
tainted by stigma that compromises the potential for genuine dialogue.
Supervision help therapists to appreciate the relief that may come from
the joint understanding of fragments of experience. In other words,
supervision can help therapists see how a shared understanding of a
fragment of experience may be no less powerful than a shared understand-
ing of a complex idea about oneself or others. Certainly, a shared
understanding of any kind of fragmented experience requires the presence
of a therapist as someone relating to the dilemmas as part of the human
condition. Of note, some therapists may neglect the idea of joining because
they have a general assumption that the patient is already someone the
therapist understands and knows. This may appear in the form of
assumptions from the therapist that the patient is a mirror of how they,
the therapist, generally understands others.
Beyond issues of stigma or wanting to ‘‘ﬁx,’’ it may also be discovered in
supervision that therapists are not joining the patient because they
fundamentally view fragmentation as dangerous and something that could
not be jointly understood, and therefore, something to be made whole ﬁrst.
Since within this view joint meaning making is not possible, therapists may
think they can only ‘‘ﬁx’’ fragmentation by sharing information with the
patient or prescribing healing activities to them. This stance that fragmen-
tation cannot be mutually understood can be potentially rooted in or
reinforced by some phenomenological accounts of psychosis which posit
these experiences as outside of understanding (Sass, 2013). This stance may
be underneath the surface as therapists simply try to explain something to a
patient about the patient’s experience, or it can manifest as therapists try to
teach patients their theories.
Supervision here may help the therapist name this stance and think about
both its origins and potential lack of utility, perhaps again through use of
analogy (e.g., the calculus student). Supervision can also actively challenge
preemptive assumptions by therapists that they ‘‘know’’ the patient on the
basis of having already ‘‘taken their history.’’ Supervision can gently
challenge shallow or premature understanding of patients by thinking about
any number of fragments of self-experience that have emerged but have
already been forgotten by the therapist. It can also easily challenge, through
simple joint reﬂective activities with therapists, any notion that patient
verbalizations do not communicate anything. Thus, it can assist therapists to
recognize pain often not readily obvious in more disorganized forms of
speech. For example, the patient who appears preoccupied with grandiose
296 LYSAKER, BUCK, PATTISON, BEASLEY, HILLIS AND HAMM
aspects of the self might experience a deep sense of inadequacy. In this
example, the supervisor might encourage the therapist to reﬂect on their
own experiences of feeling inadequate and corresponding desires to engage
in grandiose thought or activity to alleviate such feelings.
The failure to join with patients may also occur when certain themes
emerge or threaten to emerge within a session. This could include
aggressive or sexual themes which emerge when certain fragments of self-
experience are activated. Other themes that can trigger therapists to
disengage from an intersubjective experience can include severe inertia on
the part of the patient or jealousy of the therapist, which may be tied directly
to patient awareness of the real-world inequity (e.g. ﬁnancial/social
privileges, disparities in exposure to trauma, or injustice) and which the
therapist may be uncomfortable bringing into their awareness. Failure to
join the patient might be represented by therapists’ tendency to want to
conduct repetitive risk assessments when aggressive themes emerge, insist
the patient is aware of his or her own thoughts when experiencing severe
inertia, or communicate to the patient or supervisor that the therapist is an
advocate for social justice. Turning to the broader issue of supervision,
again in the manner of parallel process, while the supervisor might feel
urged to ‘‘get’’ the supervisee to ‘‘stop’’ doing something or to ‘‘start doing’’
something else when they are not joining the patient, the supervisor must
instead understand how to join the therapist. The task is not to ‘‘ﬁx’’ the
supervisee’s underlying assumptions and basic responses but to promote
joint awareness and reﬂections about those.
While therapists may readily master how to respond to fragments
characterized by common human emotions, such as fear, sadness, and
anxiety, there may be more difﬁculty when the fragmented experience of
patients involves increasingly anomalous experiences such as thought
insertion, socially unacceptable content (e.g., vividly aggressive or sexual
ideation), or profoundly barren states in which patients report no thoughts or
emotions. Nevertheless, the task is the same for the therapist and also for the
supervisor regardless of the experience if it is to be a subject of joint
reﬂection. The experience of thought disorder could, for example, be
related to times the therapist has felt urges or had wishes that were
completely ego dystonic, and it might have been comforting to see them as
coming from outside the self. Vivid aggressive images could be recognized
by linking them to an experience of road rage while severe emptiness could
be related to by thinking about a time during signiﬁcant grief or mourning
when the therapist was exhausted and truly felt he or she had nothing to say
Of note, the process of joining the patient and thinking together about the
experience of the fragments of themselves is fundamentally a dialogical
SUPERVISION IN THE PSYCHOTHERAPY OF SCHIZOPHRENIA 297
task, and in this regard, it is inevitable and necessary that therapists have
different thoughts from their patients and supervisors. In other words, in
addition to thoughts that complement the patient’s thoughts, the therapist is
likely to have thoughts that are either unrelated to or contradict the thoughts
of the patient and supervisor. This may include instances wherein therapists
have ideas that seem incompatible with previous training. For example, a
therapist might fear that if they acknowledge the rageful aspect of a patient
that they will somehow afﬁrm the stigmatizing view that mental illness
means dangerousness, which may conﬂict with their desire to advocate
against social injustice and stigma experienced by people with serious
mental illness. Likewise, they might fear that noticing a poor choice on the
part of the patient might similarly afﬁrm the stigmatizing belief that mental
illness means incompetence or that challenging a patient’s view of
themselves may further invalidate a weak sense of self. Here supervision
may effectively rely on self-disclosure on the part of the supervisor to help
therapists see that we all have aspects of ourselves which are less competent
or disagreeable, and we are always in a ﬂuid dialogue with others about
who we are. This kind of dialogue promotes the larger notion that ultimately
a full life does not necessarily come from pretending that unwanted or
unpleasant parts of the self do not exist.
For some therapists, however, even more basic supervision may be
necessary. Some therapists have largely experienced previous training
emphasizing only what the therapist does but not why or how they do it. It
may have been assumed, following a line from the poet Gertrude Stein that
a ‘‘Rose is a rose is a rose is a rose,’’ that an intervention is an intervention is
an intervention. In previous training, human suffering may have been
treated as a discrete set of categories which can be plainly reported and
identiﬁed by any human being and for which a series of proven solutions are
available to the willing therapist and patient. Similarly, certain interventions
may have been previously conceptualized without reference to patients’
metacognitive capacity. In supervision, then, a task for supervisors is to
think with therapists about their practice, and how an intervention
supplying meaning is not the same as an intervention in which meaning
is made jointly when addressing fragmentation, even if each reaches the
CONCLUSIONS AND FUTURE CONSIDERATIONS
In this paper, we explored two major nuances of supervision meant to assist
therapists to respond to the fragmentation of self-experience in patients with
schizophrenia spectrum disorders. We have discussed speciﬁcally how
298 LYSAKER, BUCK, PATTISON, BEASLEY, HILLIS AND HAMM
supervision can support therapists to be able to genuinely notice and
appreciate the experience of fragmentation, and ultimately to join patients
and share in that experience and begin to make meaning of it. We have
discussed how this may call for examination of therapists’ basic experience
of, fundamental beliefs about, and automatic responses to fragmentation. It
is hoped that our exploration of these issues will support the development
and implementation of these methods more broadly over time.
This work, though, is only a beginning, and there are other complex
issues involved in this form of supervision for which there is not sufﬁcient
space to explore here. These include how supervision can help therapists
respond to slow and uneven progress, understand breaks in therapy, and use
self-disclosure, as well as to explore how integration and increased
awareness might breed pain (Buck et al,2013). There are also other more
speciﬁc techniques that may assist therapists in understanding the experi-
ence of fragmentation and subsequent recovery, including the use of
literature in group supervision (Hamm et al,2014; Leonhardt et al,2015).
Many empirical questions remain as well, including how the therapeutic
alliance should unfold in this kind of work. Further, what are the subjective
experiences of the therapist within supervision? How does this work affect
how therapists think about themselves and their professional work more
broadly? Answers to these questions are needed to help understand what
kinds of therapists are best suited for this work and could beneﬁt from these
kinds of supervision.
1. Paul H. Lysaker, Ph.D., is a clinical psychologist at the Richard L Roudebush VA Medical
Center and a Professor of Clinical Psychology in the Department of Psychiatry at the
Indiana University School of Medicine. He is an author of over 450 papers published in
peer reviewed journals. His current research interests include the metacognitive,
phenomenology and psychotherapy for psychosis in adults.
2. Kelly D. Buck, PMHCNS-BC, is a clinical nurse specialist at the Richard L Roudebush VA
Medical Center. She is an author of over 50 papers published in peer reviewed journals.
Her current research interests include the metacognitive, recovery and psychotherapy for
psychosis in adults.
3. Michelle L. Pattison, M.A., is a doctoral student at the University of Indianapolis. Her
research interests include understanding ways in which self-reﬂection occurs in a SMI
population throughout the course of therapy, stigma, and recovery-oriented care. Previous
research has focused on insight, double stigma, and the promotion of recovery through
utilizing Metacognitive Reﬂection and Insight Therapy (MERIT).
SUPERVISION IN THE PSYCHOTHERAPY OF SCHIZOPHRENIA 299
4. Rhianna E. Beasley, M. A., is a doctoral student in clinical psychology at the University of
Indianapolis. She is currently a trainee in the Psychosocial Rehabilitation and Recovery
Center (PRRC) at the Roudebush VA Medical Center, and has had previous training in
private practice and community mental health. Her research interests include the
psychotherapy of serious mental illness, and the intersection of psychosis and trauma.
5. Jaclyn D. Hillis, Psy. D., is a clinical psychologist at the Chillicothe VA Medical Center.
She currently provides and supervises MERIT informed psychotherapy for veterans with
prolonged and early psychosis. Her current interests include understanding the inﬂuence of
metacognitive growth on self-efﬁcacy.
6. Jay A. Hamm, Psy.D., is a clinical psychologist at Eskenazi Health Midtown Community
Mental Health in Indianapolis, Indiana, USA and clinical assistant professor with Purdue
University, College of Pharmacy. He has published more than 40 peer-reviewed articles
and several book chapters on serious mental illness, psychosis, recovery-oriented
psychotherapy, and metacognition. His clinical work is focused on providing metacog-
nitive psychotherapy to adults diagnosed with serious mental illness and he actively
supervises clinical psychology trainees and community mental health staff.
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