The Clinical (non)Decision-Making Process in Understanding Schizophrenia: Looking to be Spontaneous and Carefree

The clinical picture of schizophrenia questions an essential aspect of decision-making in the clinical process, particularly with regard to the narrative expression of personal experience. Traditionally, it has been believed that an interpersonal interaction centred around one’s innermost core can be crucial for an individual, whether mentally ill or not. This therapeutic approach, certainly influenced by Freudian psychoanalysis, enables the individual’s inner world to unfold, implicitly suggesting that a more liveable world is revealed once this process occurs. It is important to notice that the therapeutic benefit is achieved through a collaborative process and a dialogue constructed between the individual and the therapist.
However, individuals in distress often rely excessively on narrating their own experiences. This is known to be particularly the case in schizophrenia because of the now familiar phenomenon of hyper-reflexivity. It is concerning to observe that the main therapeutic approach—discussing one’s experiences—overlaps with a cardinal symptom of the disorder (even though this of course needs to be nuanced).
In this contribution to the debate on clinical decision-making in psychopathology, I propose that a coherent therapeutic approach for patients who question life rather than live it is to help them engage less in analysing their experiences and instead to connect with them on a pre-reflective level. The goal is to provide them with opportunities to rediscover the carefree nature of life and experience a spontaneity that does not constantly call things into question. This clinical approach, which should be intuitive for any therapist, is unique in that it is inherently therapeutic, yet it is pursued without any specific therapeutic objective. In these instances, clinicians may not fully understand why they are engaging in certain actions. They are living life alongside their patient, rather than simply analysing things. In this context, I present a series of clinical scenarios that highlight the informal moments between therapists and patients, during which therapists may appear to be deviating from their role although in fact they are engaging in the most subtle ethical aspect of the clinical experience.