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PSYCHOPATHOLOGICAL NARRATIVE FORMS
Journal of Constructivist Psychology, 14:1–23, 2001
Copyright ã 2001 Brunner-Routledge
1072-0537/01 $12.00 + .00
PSYCHOPATHOLOGICAL NARRATIVE FORMS
GIANCARLO DIMAGGIO and ANTONIO SEMERARI
Associazione di Psicologia Cognitiva (A.P.C.) — III Centro
di Psicoterapia Cognitiva, Rome, Italy
During psychotherapy, patients describe their experiences in the form of storytelling.
Our goal here is to define the criteria that will allow a therapist to distinguish an
effective narrative from a dysfunctional one. On the basis of a number of criteria,
we provide a classification of the psychopathological forms that can be taken by the
discourse of patients observed during psychotherapy. Two main categories are
described: (a) Impoverished narratives, which are divided into the subcategories,
Deficit in Narrative Production and Alexithymical Narratives; and (b) Integration
deficit which is subdivided into Basic integration deficit, Deficit in integration
between multiple representations of self and of others, Overproduction of narratives
and deficit in hierarchization, and lastly Deficit in attribution to the correct mental
function and deficit in distinction between reality and fantasy (between primary
and disconnected representations).
Our interest is in discussing the characteristics that narratives need to
have in order to guide an individual’s actions in the world. In particu-
lar, we shall try to provide an answer to the question: what conditions
render a narrative unsuitable for its objective, and what forms do patho-
logical narratives take? We shall try to give a clinical description of
the forms taken by these dysfunctions, so that they can be treated
correctly by the therapist. Listening to stories related during psycho-
therapy is both a working method and the field of observation.
Research into psychotherapy has already produced data that show
storytelling is very common in sessions (Luborsky, Barber, & Diguer,
1992). These data also show that various types of narrative lead to
different outcomes in psychotherapy. For example, patients whose pre-
vailing narrative form is the so-called reflexive one (one in which pa-
tients speak in the reflexive mode when they refer to interpretations,
Received 30 November 1999; accepted 1 May 2000.
This study is supported by the National Project of Health of the Institute Superiore
di Sanità, Contract Nr 96Q/T/23.
Address correspondence to Giancarlo Dimaggio, III Centro di Psicoterapia Cognitiva,
via Ravenna 9/c 00161, Rome, Italy. E-mail: terzocentro@iol.it
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G. Dimaggio and A. Semerari
meaning construction, and subjective aspects of the experience) achieve
a better outcome (Angus, Hardtke, 1994; Gonçalves, Korman, & An-
gus, 2000). Finally, data also show that narrating as an activity has a
therapeutic value for both physical and mental health, and that vari-
ous types of story correspond to different outcomes (Pennebaker, 1993).
The present work therefore aims to categorize the various types of
narrative produced during psychotherapy and their organization in
an individual’s cognitive system. This first step could then provide a
guide to research on the psychotherapy process. The goal is to evalu-
ate the changes to which the various types of narrative are exposed.
Furthermore, once specific forms of narrative dysfunction have been
identified, it will be possible to guide the process of constructing and
rewriting a patient’s meaning system with greater precision. Patients
who are incapable of telling stories about themselves can be helped to
do so, and patients who tell stories in a confused fashion can be helped
to dissect and reorganize their narrative style.
THE EFFECTIVENESS OF NARRATIVES:
STORIES RELATED DURING SESSIONS
We shall reply clinically to the question: what characteristics do stories
need to have to be effective and to allow an individual an appropriate
action in the world? What structure should a patient’s narrative have to
permit a therapist to be effective and to help him or her? This allows us
to get closer to understanding the pathology of the narrative function.
As they try to transmit their knowledge about their selves to the
therapist who is listening to them, patients keep to their personal style,
they express points of view about the world, theories that are worked
out to a greater or lesser extent on how things are going or ought to be
going and on how their life is or ought to be. The main tool that they
use is storytelling. They tell about events from their present and past
lives, or how they imagine them to be, with the selves, significant
others, or the bizarre characters that inhabit their dreams as protago-
nists. Therapists gather information from their narratives, and this
guides them in their requests for further narratives or details about
stories that have already been related, thus increasing understanding
of the persons with whom the therapists are talking.
Not all stories are equally effective in promoting understanding
and clear statement of problems and in increasing shared knowledge.
A depressed patient during a session in the second month of psycho-
therapy relates the following episode:
Psychopathological Narrative Forms
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P.: It’s always the same problem that I don’t know how to tackle.
I had to sit for the exam, I mean the test before the exam. Before I
got up I was terribly anxious. I knew it was my turn and I was
thinking: “This is it; I’ll go in and they’ll find I haven’t prepared
properly and that I’m unable to explain well what I know, and
they’ll consider me incapable.” I also think that I don’t know how
to explain things well and don’t understand them. Then I got up
and went in.
T.: How did the oral go?
P.: As I expected, I got embarrassed, I blushed and I thought,
“Now they’ll notice that I’m embarrassed,” and this blocked me
even more.
This is, in our opinion, a good narrative. The patient is capable
of putting events in a space-time sequence, of supplying information
relevant to the problem, of describing clearly his inner states, of find-
ing access to his own thoughts and emotions and of giving the listener
the means to get to know them. There is a clear description of the
problem: overcoming the feelings of anxiety and shame and the nega-
tive opinion that others have of him and that he has of himself. The
patient is not very confident that things can change and his appraisal
of himself is doggedly negative: “I also think that I don’t know how to
explain things well and don’t understand them.” But both persons
taking part in the dialogue have easy access to the problem. More-
over, the story has defined time and space boundaries and does not
get mixed up and confused with other stories, and the information
given is relevant. Without doubt the speaker adheres to Grice’s (1975)
cooperative principle of conversation (quality, quantity, manner, and
relevance) and knows that, when one asks another person for help,
it is necessary to grant the other access to one’s emotions.
A good narrative during therapy should therefore have the fol-
lowing structure.
1.It should be set out in a well-ordered space-time sequence, so
that the chronological order and potential relationships of cause
and effect can be identified;
2. It should make explicit reference to inner states, in particular
emotional experiences;
3.It should include a description of the problem that is clear or
at least easy to construct;
4.It should be put together with, as a reference point, a developed
theory of mind of the listener, taking account of the knowledge
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G. Dimaggio and A. Semerari
available, the concerns and information the listener possesses
and of the listener’s psychological skills and intelligence;
5.It should be relevant to the interpersonal context (that of treat-
ment in the case of narrative during therapy);
6.It should be endowed with an adequate thematic coherence and
merge only partially with other narratives (i.e., there is a limit
to the number of brackets and parentheses that can be opened
without the listener losing the thread of a talk);
7.It should provide relevant knowledge, of well-defined areas in
the world of relationships;
8.It should integrate inner states and reflect at least in part so-
matic states and emotions felt and expressed in coherent mean-
ing themes. This operation, as indicated by Guidano (1987), is
by definition unending and incomplete, as it is not possible to
give a meaning to everything we experience, and there is al-
ways an uncanny element that stays left out.
9.An individual needs to have the ability to imagine multiple
stories. The world of relationships is complicated and each in-
dividual has to interpret numerous roles. People therefore have
to have enough scripts at hand to guide them on how to behave
as inner and interpersonal contexts change.
These are the conditions necessary for a narrative to operate well.
A narrative that does not adhere to them is problematic and it is pos-
sible to describe the pathological forms it takes—the forms of narra-
tive disruption, to use the words of Neimeyer (2000).
In what ways can storytelling during therapy fail in its objectives
of communicating knowledge to another person or constructing an
agreed text as a basis for building meanings and resolving problems?
Let’s summarize schematically the various categories of narrative
dysfunction.
1.Impoverished Narrative.
a.Deficit in Narrative Production,
b.Alexithymical Narratives.
2. Deficit in Narrative Integration.
a.Basic Integration Deficit.
b.Deficit in Integration Between Multiple Self-Other Represen-
tations.
c.Overproduction of Narratives and Deficit in Hierarchization.
d.Deficit in Attribution to the Correct Mental Function and Def-
icit in Distinction Between Reality and Fantasy (Between Pri-
mary and Disconnected Representation).
Psychopathological Narrative Forms
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INEFFECTIVE NARRATIVES: CLINICAL EXAMPLES.
IMPOVERISHED NARRATIVE
Let’s subdivide impoverished narratives into two categories: Deficit in
Narrative Production and Alexithymical Narratives. With impoverished
narrative, the problem is not in the internal structure of the story,
which can be coherent and clear. The problem is that the patient does
not have a set of stories sufficient to cope with the world of relation-
ships. Often these patients also suffer from alexithymia and other defi-
cits in the higher mental functions, but the crucial point is their im-
poverished cognitive system. Alexithymical narratives do not refer to
emotional states and do not contain comprehensible descriptions
of problems that the therapist should be tackling. In general, they do
not take much account of the listener’s perspective. Lastly, somatic
experience is not integrated with emotions and with the meaning of
events.
Marcello provides a good example of impoverished narrative. It
can be seen in the texts reproduced below how he brings up almost
only one theme: the scenario is monotonous, emotions are few, the
communication of meanings is weak, one does not understand from
them the complexity of the world in which he lives. He is a young
man, 28 years old, with a defect in his intellectual development that is
probably due to emotional traumas at an early age. There were abduc-
tion and shooting incidents between his parents at the time they were
separating, when he was three and a half years old. Custody of Marcello
was granted to his father, who then asked the aunts on the mother’s
side for assistance. Marcello lived with them until he was 11 years old
and then went back to live with his father, switching between South-
ern and Central Italy. Not since he was three and a half years old had
he seen his mother. Marcello was extremely sensitive with regard to
the negative judgment of others. He had a tendency to feel threatened
and therefore reacted with anxiety and anger. His proneness to shame
prevented him from verbally narrating stories that included problem-
atic emotions. Initial efforts were to encourage Marcello to write freely
on the themes of his choice during a group workshop whose aim was
to foster self-exploration. His earliest texts were concise and compre-
hensible, but scanty. He showed few emotions but related that he ex-
perienced strong feelings when he was asked to narrate for the first
time. After establishing a good relationship with the female workshop
leader, Marcello was also asked to write about unpleasant emotions
and daily events that he felt to be important. The average number of
texts written per week was about one. The numbering that follows
indicates their chronological order.

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