Encountering Psychosis in a Dialogically Informed Psychotherapy Session: A Single-Case Study

Theories of dialogism suggest that dialogical relationships may drive therapeutic change with people diagnosed with psychosis, yet how this occurs in practice remains unclear. This study examines the emergence of dialogical engagement in a psychotherapy session with a person experiencing psychosis and how his expressions shift over the course of the session. A single 45-min session was descriptively analyzed using Conversation Analysis-informed case analysis. A young adult male referred to as Jack presented with experiences interpreted as paranoid ideation, low treatment engagement, and limited response to medication. Dialogical and monological sequences were identified through turn-by-turn analysis, focusing on the therapist's stance, interactional flow, and Jack’s responses. Topic development and epistemic positioning were central analytic foci. Dialogical engagement was fostered through open-ended questions, reflective responses, repetition, and emotional attunement—supporting meaning-making and reflective positioning without pathologizing Jack’s beliefs. Moments of rupture following directive therapist moves required active realignment. Although Jack initially expressed a desire to discontinue therapy, he reported emotional relief and openness to continue. Despite limited polyphony in a one-on-one session, the findings suggest that interactional practices promoting dialogue may still support collaboration and meaningful engagement with people diagnosed with psychosis, while also generating themes relevant for more conventional psychotherapy.