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DISORGANIZED NARRATIVES:
PROBLEMS IN TREATMENT AND
THERAPIST INTERVENTION HIERARCHY
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.
191
192 G. Salvatore et al.
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.
Lucias History1
1
The name is fictitious.
Treatment of Disorganized Narratives 195
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.
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.
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.
Emotional Validation
I could have been dealing with other things . . . This is a positive fact.
While I was finishing this, I felt satisfied.
me, beyond the fact that I was awake all night and couldnt wait for
the morning to come and . . .
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.
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.
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 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
References