ORIGINAL PAPER The Mutual Development of Intersubjectivity and Metacognitive Capacity in the Psychotherapy for Persons with Schizophrenia Paul H. Lysaker • Kelly D. Buck • Rebecca L. Fogley • Jamie Ringer • Susanne Harder • Ilanit Hasson-Ohayon • Kyle Olesek • Megan L. A. Grant • Giancarlo Dimaggio Published online: 31 August 2012 Ó Springer Science+Business Media, LLC (outside the USA) 2012 Abstract While cognitive behavioral approaches have been shown to help some individuals with schizophrenia, these approaches may be limited when working with patients with impairments in the metacognitive abilities required to form complex and integrated representations of themselves and others. In response, this paper explores the possibility that a key to working with patients with rela- tively impaired self-reflectivity lies in explicitly focusing on a patient’s intersubjective experience within psycho- therapy. We offer theoretical and empirical support for the assertion that the tolerance and capacity for intersubjec- tivity is a basis for the development of self-reflectivity in general. We also explore how the fostering of intersub- jective processes in psychotherapy might enable some patients to form more complex ideas about themselves and so better ward off delusions in the face of the challenges of daily life. To illustrate these principles we present the case of a patient with tenaciously held delusions and limited capacity for self-reflection. We discuss when and how the therapist’s awareness and verbalization of intersubjective processes within session allowed her and the patient to develop more complex and consensually valid ideas about him as a being in the world, which then assisted the patient to achieve improvements in a number of domains in his life. Keywords Metacognition Á Intersubjectivity Á Delusions Á Narrative Á Schizophrenia Á Recovery Á Psychotherapy Recent emphasis on recovery as an achievable outcome from schizophrenia (Lysaker et al. 2009; Roe 2001; Silverstein and Bellack 2008) has led to renewed interest in integrating non-pharmacological interventions such as psychotherapy into routine treatment. To date, the most commonly reported form of psychotherapy that has been empirically studied with patients with schizophrenia is cognitive behavioral therapy (CBT). As detailed in a range of sources, these interventions seek to assist patients to recognize and correct dysfunctional thoughts and behaviors (Kingdon and Turkington 2004; Rector and Beck 2002). Furthermore, they have been found to be effective, par- ticularly with regard to reducing positive (e.g. Sensky et al. 2000) and more recently negative symptoms (Grant et al. 2012). Though less studied, research has also suggested the potential of psychodynamic psychotherapy to help persons with schizophrenia (e.g. Furlan and Benedetti 1985). Despite the effectiveness of CBT, a number of different groups have identified a need to expand cognitively-based P. H. Lysaker (&) Department of Psychiatry, Roudebush VA Medical Center and the Indiana University School of Medicine, 116H 1481 West 10th St, Indianapolis, IN 46202, USA e-mail: plysaker@iupui.edu K. D. Buck Á J. Ringer Roudebush VA Medical Center, Indianapolis, IN, USA R. L. Fogley Á K. Olesek Á M. L. A. Grant University of Indianapolis, Indianapolis, IN, USA S. Harder Department of Psychology, The University Clinic, University of Copenhagen, Copenhagen, Denmark I. Hasson-Ohayon Department of Psychology, Bar-Ilan University, Ramat-Gan, Israel G. Dimaggio Centro di Terapia Metacognitiva Interpersonale, Clinical Psychology Specialization Program, University ‘‘La Sapienza’’, Rome, Italy 123 J Contemp Psychother (2013) 43:63–72 DOI 10.1007/s10879-012-9218-4