Bibliotherapy and Schizophrenia: A Stanghellinian Perspective Open Access

Schizophrenia carried for long the “postulate of irreversible degeneration [translated]”, of an impossible remission from the pre-morbid state, conditioning “the subject’s existence to the so-called pejorative evolution of the disorder [translated]” [1]. Bleuler [2] did believe that this disorder did not allow “a full restitutio ad integrum”, and this view long prevailed in what this diagnosis spontaneously seemed to imply [1, 3, 4], but the discovery of a diversity of risk factors opened the view to a diversity of prognoses [1], and Warner’s work [5] is emblematic of this. Schizophrenia became less associated to deterioration, and some reproduced Warner’s method, showing “that a significant proportion of people who receive a schizophrenia diagnosis make a good recovery” [6]. Another study tends “to debunk the myth that schizophrenia inevitably has a deteriorating course” [7], and this result legitimizes clinical prospects. Several clinical tools have been evaluated in schizophrenia [5, 8‒10], but the need to work with lived experience remains fundamental [1, 11‒13]. This movement, from therapies centred on chemical medication and bodily interventions to those centred on the talking and the person, is a long movement, full of back-and-forth and dominant trends, stretching from the early 19th century to the present day, and which has traversed the history of schizophrenia treatment as much as that in psychiatry [1, 3, 4, 12]. In this movement, schizophrenia has seen a major evolution in its care from the re-education of habits and faculties of mind, at the time of moral treatment, to asylums and chemo-viral solutions, at the time of positivism, the 19th century gradually turned its attention to the body. But the 20th century, under the pressure of psychoanalytical and existential approaches, returned to the mind, and sought, through the power of the spoken word, to give these people the opportunity to rebuild a habitable I, capable of personal growth, while bio-medical approaches continued to progress and assist this view. A return to the person seems to have been a key part of history of this care, and over the last few decades, several approaches have consolidated this orientation, which has gradually taken on the appearance of a necessity. Between the psychotherapeutic, institutional, bio-medical conventional approaches, various methods (e.g., art-therapy, psychosocial rehabilitation, peer support) have been developed to help these persons, while respecting this necessity of a disorder- and person-centred approach, and, to this end, we will look at the opportunity of bibliotherapy because this therapeutic framework seems to refer as much to cognitive issues as to existential ones.

Bibliotherapy has origins from ancient history to our time [14‒17]. In 1916, the term was coined, in 1941 it appears in a medical dictionary, defining “the employment of books and reading them in the treatment of nervous diseases” [17]. Initially part of occupational care, it took several forms shaped to a diversity of sets [14], and some [18] saw that it remains a type of “miscellaneous collection of techniques and practices in which literature is used in some way”. Alone or not, ill or not, reading aloud or not a poem, or a self-help book, bibliotherapy is the therapeutic use of books. Here, the bibliotherapy we are interested in is based on literary fictions. This type of text can be defined as narrative (i.e., relating events, characters), fictional (i.e., presented as non-factual), literary (i.e., with aesthetic, canonical qualities) [19], and these aspects point out the complexity of a text’s situations and expressions, thus to the mentalizing efforts it elicits [20], and this definition makes it possible to scientifically study a text, to see its effects in mind. Reading literary fiction can thus reduce cognitive biases [20‒23] and improve social [24, 25] and emotional cognition [26, 27], but what emerges is that instead of engaging a verification process, deconstructing narrative elements like a non-fiction [28], it opens a mind’s flight simulator [24], a mental role-taking, adopting another point of view, and defamiliarization, alternative-troubling view on experience [19]. By reading literary fictions, we use “processes of engagement in literature” related to its neural correlates; the inferential-semantic making of situational models linked to the narrative, within which a sense of immersion and imagined representations take place [29]. By reading fiction, we do not have the text in a side and the reader away but a mental encounter, because we do not passively simulate the narrative. We make the inferences that will “fill in the blanks” of the narrative and enrich its approximations with daily emotions, memories, experiences, interpretations [30]. Unlike a model reader following the narrative [31], there is a co-construction between artistic and aesthetic poles [32], the text-set and the reader-stager. Thus, bibliotherapy could support a care concerned with the phenomenological and narrative layers that would be cognitively efficient [33], and focused on existential questioning, caring for the self and its existence [14, 34, 35].

Concerning clinical phenomenology, there has always been psychiatric person-centred views [4], but recent increases of interest for the total person, not exclusively the disorder, took on a greater impact [36], just like the former paradigm, due to its return to the thing itself, its description of experience. Its refusal of naturalistic reductionism to grasp and express lived experiences interests some to meet other lived conditions. The idea is not to take off objectivity, but to complement it with one’s experience, and to value it in care, to rehabilitate a first-person perspective [37], the I in clinical alliance and evolution [38]. The phenomenological psychiatry [39] greatly assists this personalized care as it provides a subjectivizing posture, and some tools. By focusing care on the overall phenomena of any mental disorder, this approach strives to account for any concrete lived world. Self and world often polarize phenomenological studies [40, 41], and thus, the schizophrenic lived self [42] shows a Gestalt aspect [43] allowing us to identify its traits: hyper-reflexivity, exaggerated awareness of implicit processes, diminished self-affection, declined sense of being an embodied, acting subject, disturbing of grasping the world, altered sense of being embodied in a stable, accessible, salient world [44]. These studies show an altered lived self in this disorder [45, 46], but this paradigm also informs on its lived world [47], where these anomalies seem less unified, more idiosyncratic than of the self [43, 48], but despite this variability, they are highly present and intercorrelated in schizophrenia [48]. Thus, these data support that schizophrenia involves a total experience [43], a life-world (“originary domain of everyday experience”) [49] disrupting the “overall presence” [48], daily lived, seen by the person.

Also, a change of outlook [50] has taken place recently between the rise of users movements, the reversal of fatalism, the taking into account of lived experience, and schizophrenia is no stranger to this new view [1, 50‒55], which, based of phenomenology, institutional psychotherapy, diversity of causes-prognoses, leads to personal recovery. By thinking care from the person, this approach defines the process by which one existentially go beyond its disorder, independently of its symptomatic-functional condition [1]. Some studies contrast this point, and show correlations between this subjective process and the objective state [51, 53], but personal recovery can be defined as intimate processes (i.e., enhanced sense of connections, hope, identity, meaning, empowerment) [51, 55] leading, in schizophrenia, to a narrative redefinition, in which the self becomes aware of its disorder, accepts it, and transcends it [1].

In short, it positioned the person at the heart of the care by giving one’s a major role in its evolution. To us, bibliotherapy could feed a care centred on personal recovery as it can be inscribed in this care of the self, concerned with existential becoming. However, before ruling on this possibility, it is wise to say that bibliotherapy is part of the psychotherapeutic framework, which, with people suffering of this disorder, must not only address their experiences and worldview, but also be contained in an interpersonal framework [1, 17, 35, 55]. As Carney and Robertson [56] point out, “exposure to fiction does not, on its own, have an immediate impact on well-being”. We cannot prescribe existential turns, but only encourage the person to express the features of its existence, to reflect and share on them, and a person with schizophrenia needs this [49]. Challenging psychotherapy for these persons is an actual topic [1, 12, 13, 49, 55, 57], and bibliotherapy seems good for it [14, 33‒35] as it offers a subjectivizing stance, and a massive repertory of situations suitable for a recovery-based bibliotherapy.

To explore this idea we will look at to the work of Giovanni Stanghellini, who perpetuates this care at the minimal and narrative level. To this end, Stanghellini [49] proposes to focus on the life-world (total immediate field of experience), and the dialectical (psychic assimilation of lived alterity through meaning-making) and dialogical principles (consciousness is framed by dialogue process), in order to work with each existence and ways of dealing with it. He also drew on the notion of position-taking, one’s existential stance to its experience, to develop his proactive person-centred care [58].

He also shaped an epistemological idea that could, to us, help the care: the image [59, 60]. Here, an image does not refer to a visual one (e.g., painting), but to its epistemological value, to a form which does not translate a strict reality, but offers a relay for understanding. The image is not perfect, nor sufficient, but this insufficiency necessitates keeping what Ricoeur [61] called “the spark of imagination into a ‘thinking more’”, a “‘twist’ of the literal meaning of the words”, intended to open understanding, not to a determined explanation. For him, the use of images, literal or metaphorical, could abrogate psychiatric linear causal thinking, in favour of the emergence of an image-based model proposing the description of a phenomenon in which an I can and must take part [59]. This use of images, vivid metaphors as Ricoeur [61] says, is not out of poetry, and this prevents of what Stanghellini [60] calls narrative compulsion, the abusive trend to all signify strictly, by fostering parataxis, joining of images formally impertinent but personally relevant. The epistemological value of image also has a clinical impact, insofar as its indeterminacy is notfloating, but linked to the uniqueness of each situation, experience, way of grasping one’s life, and this person-centred approach is, as Stanghellini [59, 60] says, necessary to the care of disorders like schizophrenia. But, it is striking that Stanghellini [59, 60, 62] uses artistic and literary illustrations, like Aby Warburg, Hölderlin or Baudelaire to describe the power of images. To him, they are creators of images, pictorial or not, that sabotage the rigid, strictly defining thinking. They show the living reality we experience, that perpetually eludes the formalist urgings of naturalism. This reality, crossing life-world and world-view, is present in psychiatry, because here we meet an I resistant to the tempting attempt of scientistic reification. These images are not conceptual, but they do not invalidate understanding as they are ante litteram [60], not a-litteram, and this epistemology shares that of literary fiction and of bibliotherapy since a literary narrative fiction is ante litteram too, prior to concepts. It evokes what it says, but never circumscribes it conceptually. Bibliotherapy could hence fit with Stanghellini’s [49] Phenomenology, Hermeneutics and Psycho-Dynamic model (PHD), based on life-world, dialectic and dialogical principles, but also on phenomenological unfolding, grasping disturbing lived experiences, hermeneutic analysis, grasping and opening up interpretations, psychodynamic analysis, grasping and overcoming existential adversities. Hence, its aim is not to get “an accurate knowledge about oneself”, but to restore an “intimate form of dialogue with oneself and with others” [49], another stance towards disorder’s alterity [58], and bibliotherapy with literary fictions seems fertile to the pheno-existential focus of this model [14, 33‒35].

To us, the repertoire of literary fictions would be perfectly suited to the PHD model. Indeed, the images Stanghellini refers could be a novel or a short story; the idea is not to find the key story that will perfectly define an experience, but a story that will serve in therapy to maintain the impulse to grasp this experience, its daily meaning, the existential vulnerability in which it is embedded. The corpus of literary fiction can be like a storehouse of scenery that one can appropriate, co-create during reading and the dialogue that surrounds it. It is not like prescribing a ready-to-illustrate experiential and existential readings, but to offer an assistance “based on a triangular mode of therapist-text-patient” [35], designed to keep an impetus of self understanding-expressing that can be adapted to this model. Then, we will show how (i) phenomenological unfolding occurs when one assumes a role-taking in the narrative via the literary register, (ii) hermeneutic analysis occurs when one is defamiliarized via the narrative’s fictional register, (iii) psychodynamic analysis occurs when one is engaged via the narrative register. Thus seen, bibliotherapy can serve as an opportunity for exploring and grasping a concrete I, which is still salutary in the context of the people suffering from schizophrenia.

Phenomenological unfolding, the exploration of the implicit, automatic and forgotten unity of the life-world [49], can be assisted by the literary register of bibliotherapy, the aesthetic and atypical quality of a narrative [19]. The literary register, as well as the literary repertoire, are suitable for containing the narration of schizophrenic experiences and simulating them to the reader during role-taking. Some narratives, such as Chekhov’s The Black Monkey [63], Kafka’s The Trial [64], Johnson’s Jesus’ Son [65] or Balzac’s Louis Lambert [66], have already demonstrated their ability to represent the lived experience of schizophrenia. Indeed, these studies show that these texts offer “a first-hand account” [65] of schizophrenia, “a unique window for understanding some of the most subjective experiences in psychosis” [67], though difficult to grasp from the inside, for the person, and the outside, for the others. This setting can also show recovery via Johnson’s Jesus’ Son [65], and thus, the literary register could provide to readers the experiential looks needed to phenomenological unfolding.

Other narratives could also serve this role-taking in schizophrenic experience, but it is more relevant to illuminate the process of metaphorical recognition of these “ineffable” experiences [68]. Because of their pre-reflexivity, these experiences must be progressively conceptualized and verbalized if they are to be properly grasped, and the use of metaphors is strongly recommended to identify and formulate these daily tacit, troubling experiences [47, 68]. To us, the “semiotic canal” of literature [69], which can also be seen as a crystallization [70], is not only suited to naming these ineffable experiences by providing the reader a possible illustration of these, but this illustration relates to Stanghellini’s images [59, 60]. Clinical dialogue also contributes to the co-creation of a formulation of these experiences [12, 13] and bibliotherapy, dialogical too, can also sustain this impulse [14, 17, 35].

Thus, bibliotherapy seems appropriate to support phenomenological unfolding as it offers the reader living with schizophrenia the possibility of reliving, during the role-taking of the narrative enabled by its literary register and expressions, its own experiential anomalies, and this, in the secure and shared register of psychotherapeutic reflexivity. Moreover, the clinician, who is also a reader can also re-live these singular experiences in the course of one’s reading, and in so doing a deeper insight into the phenomenological adversity of these daily experiences. Whether as a student [63, 65] or a therapist [67], reading literary fictions seems to improve our understanding of the daily life of people with schizophrenia, and consequently our diagnostic and relational skills. By this, bibliotherapy could contribute to a more accurate, intimate understanding. By offering a role-taking in their lived experience, bibliotherapy could then reduce the “emotional distance” [63] and increase the therapeutic alliance [67], which is frequently difficult, but decisive for their progress [71, 72]. Indeed, while reading fiction seems to reduce stigmatization towards mental illness, especially when the text is in the first-person [73], phenomenological exploration seems to improve the therapeutic alliance [38, 74].

Hermeneutic analysis, the exploration, opening up of default interpretations given to lived experiences [49], could be aided by the fictional register of bibliotherapy, the non-factual quality of a narrative [19]. Indeed, the fictional register is apt to lead the reader towards a stance that opens up other meaning-making, via defamiliarization. As a reminder, Stanghellini [49] sees these interpretations as the subject’s world-view, “the person’s philosophy of life that orients her way of experiencing reality and her actions”. Usually, people confer meaning to their experiences, but schizophrenia disturbs metacognition [75] and it affects their sense of coherence (narrative integration of a troubling event, making it comprehensible, manageable, meaningful) [76, 77]. They struggle to comprehend, to make sense of their pre-reflexive, impression-like experiences, or their reflexive, event-like ones, and this induces a worldview that, failing to enable to live with alterity, produces tensions [49].

To us, defamiliarization, linked to the fictional register of bibliotherapy, can help the person’s ability to create meaning, so that one can live with alterity, because reading fiction engages reflexive processes in another way. It leads the reader to “start looking at familiar things in a different way” [19], because unlike factuality, fiction opens to “what might have happened or could happen” [28].

By role-taking in fiction, the reader gets defamiliarized from the usual perspective of its own mental states, which are usually tacit, automatic. They see themselves feeling, thinking, reacting as they would in reality because fiction offers the immersed distance [19] needed to evaluate, change beliefs [78], i.e., when one is stigmatizing [73]. We, therefore, liken the reading of fiction to a metacognitive navigation in which one can relive its tacit world-view, by “default”, as Stanghellini [49] would say. Furthermore, this navigation is also apt to changes in worldview as it seems to diminish psychological essentialism (rapid, reductive representation) [21], need for closure (desire for quick, unambiguous solution) [22], egocentric biase (overestimation that others think like us) [23], all of which can only contribute to the enduring of a rigid, dysfunctional, malaise-inducing worldview. Reading fiction thus seems to aid a change in meaning-making, hermeneutic, metacognitive processes. It opens up to the creative and complex understandings [22, 23] needed in the care of schizophrenia [12, 79].

Psychodynamic analysis, the contextualization of experiences and interpretations in life story [49], can be aided by the narrative register of bibliotherapy [19]. Indeed, the narrative register, like in narrative engagement, are apt to the emergence of emotions and memories that are crucial to existential understanding and recovery. As a remind, while narrativity refers to texts with stories/characters, narrative engagement refers to the reader’s immersion in the text, and insofar as one is in it one will invest in it personally, as “since the self is implicated, affect-loaded memories are likely to be involved” [19]. The reader does not passively simulate the narrative, but actively makes the inferences that will enrich the narrative approximations with emotions, memories, experiences, interpretations [30]. A constructive dialogue, a flow of perceptions and ideas takes place between the artistic (object qualities) and aesthetic poles (subject’s experience) [32, 35], and this leads to a narrative simulation.

Narrative engagement, favourable to the spontaneous, personal emergence of emotions and memories [19, 30, 80], could compensate for the emotional and autobiographical difficulties that are present in schizophrenia [69, 70] by providing a clinical dialogue with an indeterminate number of elements capable of being identified, shared [35]. This phenomenon has been documented in qualitative studies of reading [70, 78], but we think that it can serve a psychodynamic analysis with affect-loaded, personal memories in order to search dialogically around the text reading and the discussion for a nexus of intelligibility, an episode in the life story which, although not signalling the onset of the disorder, like a trauma, makes related phenomena intelligible and invites to understand the existential vulnerability associated with this disorder and its pseudo-defensive functions, to overcome the limit-situation that encloses the person in a broken dialogue with alterity [49, 81]. To put it simply, the limit-situation is a Jaspersian concept used to designate a person’s existential situation in which that person experiences a tension in the face of the vulnerability that shapes one’s condition as a human being (e.g., finitude, freedom) and the direction one gives to existence, in the light of choices and the implication of a pathological condition (e.g., narcissism with the limit of possibilities, depression with freedom, guilt, hypochondria with the inherent danger of the body existence) [81]. The idea is that there is limits to our existence, a moment when we can no longer dialogue, evolve with it, and people with schizophrenia are not, as Jaspers thought following incomprehensibilityof the disease [81], foreign to this and hence to the spirit of a psychotherapy that is faithfully efficient to their hopes and goals [82]. Hence, narrative engagement within bibliotherapy could help people to recognize, accept their existential vulnerabilities, and encourage them to adopt a new stance to it [49], to life’s adversities [58].

Bibliotherapy could be thought of as a laboratory for altering, opening the self toward possible selves for the I [33, 34, 83], leading to take an active and sovereign stance in front of existential vulnerabilities [58], and re-establishing a dialogue with alterity [49] by engaging in a “spark of imagination into a ‘thinking more’”, as Ricoeur [61] would say. This narrative contextualization of the self in the light of a memory with hermeneutic force seems close to personal recovery in schizophrenia [1] as it shows how one becomes aware of the disorder, accepts it, and moves beyond it. Reading could feed this process [65, 70, 78], where the self understands, accepts, and rebuilds itself [34, 35, 84].

As a reminder, this work is part of the rehabilitation of person-centred psychotherapy in schizophrenia, not a strict therapeutic adaptation of fiction reading, and if bibliotherapy is not therefor a directive setting, insofar as there is no good reading of a text [33], but personal readings, reading disorders in schizophrenia are not problematic. Indeed, these disorders are irrelevant because if they may impair a text comprehension [85, 86], this is assessed with standardized tools foreign to lived experiences. If persons with schizophrenia misread Hemingway because they score lower on a text comprehension [87], what is reading Hemingway well if not to conform a reading to the waiting of the rater, to be an impersonal reader? Our expectations of this kind of bibliotherapy may touch on directive aspects, like social cognition [88, 89], but its richness concerns the understanding of self [84], the care of self centred on the person and its experiences, worldview, and existential adversities [49]. This non-performative use of reading literary fiction, for us, also makes it possible to avoid adversities relating to the socio-economic and cultural obstacles these persons may feel in front of reading, like its scholastic or elitist representations. In fact, the epidemiological incidence of schizophrenia seems to be correlated with income inequality (measured by the Gini coefficient [90]), and this precariousness seems to play a role in the clinical and cognitive state of these persons [91‒94], and to have a negative impact on the development of reading skills [95, 96]. Indeed, studies show that people with this disorder [85, 86] or schizotypal traits [97] have poorer reading skills, but no study to date has explored the representations, lived experiences or daily reading habits of these persons. The academic achievement of these persons seems, to us, to be representative of this state of affairs; they tend to have a lower level of university education than the general population, but the heterogeneity of the results, and since these data do not tell anything about their desire or pleasure in learning, leads us to not reject by principle that they could adhere to any kind of learning [98]. They tend to have lower reading skills, and more self-stigmatizations [99, 100], but the same heterogeneity is found here, associated with the same absence of data relating to the desire, experience and/or habits, but this is what our discussion is about, and, for us, these invite those who want to take reading into a clinical practice to remain vigilant to these risks, which can range from cognition to self-exclusion, more present than in the general population, not to closure; to remain in the maieutician’s effort, not the evaluator’s view.

Thus, this idea of a phenomenological-existential bibliotherapy for people with schizophrenia has nothing to do with a therapist’s or patient’s need for literary training since it is based on the personal, naïve reading of a text, even if one text, as we have shown, is closer to a disorder than another. Moreover, like in psychotherapy, where our proposal remains, this is based on voluntary participation. Admittedly, other mediums exist (e.g., cinema, TV series) and may be more appealing to a given subject, and even if reading involves more cognitive acts than these [101, 102] this does not invalidate the primacy of the person’s therapeutic adherence over the choice of clinical medium, which is the basis of psychotherapy, but also and above all of any authentic reading. Thus, we recommend that caregivers who want to integrate bibliotherapy into psychotherapy do so punctually, even if it takes more than one session, and voluntarily, so as not to think of this device as a medical prescription, but as an interpersonal situation that can potentiate the identification, understanding and overcoming of certain facets of the lived experience of schizophrenic disorder at a given, opportune moment of psychotherapeutic care. Likely as Stanghellini and Lysaker [41] suggest, phenomenological psychotherapy can provide a dialogical prosthesis for these persons, a “construction of micro-narratives focused on real world situations”, both experiential and social, favourable to the emergence of a sense of the self that can inter- and intra-subjectivize, live again with its disorders, the bibliotherapy presented here could provide a literary prosthesis, a support that could be punctually, voluntary, opportunely used to potentiate this well-being, of which we have theoretically drawn up a possible map, which has yet to be empirically studied, and some cognitive improvements, like social cognition [88, 89]. At present, no empirical study of literary and psychotherapeutically individual-oriented bibliotherapy with people suffering from this disorder can offer us standardized operative resources, but the study of Kasperek-Zimowska et al. [84], based on a group bibliotherapy with people with schizophrenia, shows that it is possible to structure the organization of sessions and agenda specific to it, while preserving the need for a person- and disorder-centred view. A very recent study [103] also conducted a randomized controlled trial of group bibliotherapy, including literary works among other psychological/motivational ones, and apart from showing “a significant positive effect on the psychological rehabilitation of patients with schizophrenia”, observed via anxiety, depression, self-efficacy scores, it shows above all that it is possible to structure these weekly sessions, where people were invited to discuss their emotional and experiential responses to their reading. Bembry et al. [104] also shows that it is possible to structure the agenda and sessions of a group bibliotherapy, here based on poetry reading, with people suffering from schizophrenia, as long as they are interested in reading and able to follow a discussion, thus excluding those who are actively delusional, catatonic, or affected in terms of attention, formal thought and short-term memory. As a result, even if the bibliotherapy we advocate here is essentially individual, psychotherapeutic, it is not impossible, nor absurd, that future empirical studies could further structure it. Literary reading can even be a personal, and psycho-educational, aid alongside psychological support for people with schizophrenia spectrum disorders, as Steve Colori [105] testifies in a first-person account published in Schizophrenia Bulletin, but we think it is advisable, for now, to outline the theoretical strengths and risks of this approach before putting forward concrete elements that are, in fact, still lacking in contemporary scientific literature. Thus, in addition to showing the beneficial cognitive effects, this work has presented some known and probable pheno-existential effects of reading, and their relevance for a psychotherapy with these persons.

To us, including bibliotherapy in psychotherapeutic framework would permit to explore lived experience of persons with schizophrenia, to verbalize, communicate and understand it in a different way, that is less likely to sustain existential tensions, and open the person to an other way of understanding, leading one’s life. This approach of the lived life of people with schizophrenia, apart from the fact that it can be combined with other tools for understanding, like the work of Fusar-Poli et al. [106], has above all the merit of starting from each personal situation and opening it up to the immensity of the literary corpus and dialogical exchanges. For us, it is possible to shift this adaptation to other disorders, psychiatric or not, but in schizophrenia there was an opportunity for a radical seizure given the phenomenological, hermeneutic and existential disorders that are associated with this diagnosis. Bibliotherapy could thus be a part in the growing movement for a personal recovery-based care, where, alongside the care already provided in the medical field, anyone can understand oneself and one’s problems, accept them and oneself, and overcome them existentially.

This psychotherapeutic adaptation, in our view, also calls for an epistemological adaptation, whereby the clinician encounters people’s experiences and life as such, and not as signs to be translated medically and causally, at least during clinical dialogue. To this end, we take the liberty of evoking what Smythe [107] has called, using the work of the German philosopher Hans Vaihinger [108], the “fictional stance”, an epistemology towards acts and thoughts based on three aspects: the logic of“as if” (exploratory indeterminacy of thought), background understanding (postulate of intelligibility of others), intuition (non-conceptual understanding of others). This stance would thus support to him a “psychology of “as if”, a living, indeterminate encounter with people backed by counter-factual thinking (indifference to reifying conceptualizations) and imaginative engagement (conscious use of fictions) [109]. To us, this epistemology is not only close to Stanghellini’s epistemological conceptions, in particular those previously mentioned of images and parataxis, but it also calls, like these notions, for a clinical resonance, which we would call a clinical fictionalism that could help make it possible to practice this bibliotherapy, or a psychotherapy, in a way that is centred on the person, and not on the disorder.

Finally, other embodied art-therapeutic mediations, like dance, theater, body expression can also invoke “the territorial self in clinical practice with schizophrenia” [110]. The articles on these mediations show that, despite an experimental gap similar to those on bibliotherapy, they have a certain efficiency, particularly for people with schizophrenia [111], but this reflection takes us to the frontier of the therapeutic, beyond the operative-speculative principles, where the clinician, embodied and spontaneous, “practices life instead of thinking it” [110]. This immediate-naïve space of encounter, where bodies meet in situation, is rich in daily clinical practice, but under-theorized and undervalued in scientific research. To return to bibliotherapy, it would be interesting to explore the territorial, embodied area of the books, the space where bodies meet in a shared reading situation, and by extension, this space is library. In addition to the possible akin of libraries to psychosocial rehabilitation [112], exploring the lived experience, understanding what it is to inhabit, to be in a library [113‒115] could assist this concern for narrative and territorial dimensions, both necessary to the care of people with schizophrenia and this change of outlook [50] concerning this particular clinical question.

The authors have no conflicts of interest to declare.

This work was not funded.

Florestan Delcourt, Jérôme Englebert, and Bernard Pachoud contributed to the writing of this article.