Abstract Background Something in discourse with a person experiencing psychosis often “feels off” before formal assessment is completed, yet this disturbance has not been quantified at the level of ongoing dyadic conversation. Prior work has largely treated patient speech in isolation, limiting our capacity to measure how communicative disruption emerges within clinical exchange. Methods We applied a three-level decomposition of conversational alignment in 109 patients with psychotic disorders (26 female) and 60 healthy controls (22 female) at baseline and 12 months ( n = 115). Register divergence (dAUC norm ) captured lexical distance between interviewer and patient; embedding-based synchrony (r embed ) measured semantic trajectory coupling; within-speaker coherence was computed separately for each speaker. We used linear mixed-effects models adjusted for timepoint and participant clustering. Results Patients showed significantly greater lexical-semantic divergence from the interviewer ( d = 0.48, p <.001) and reduced embedding-based synchrony ( d = −0.59, p <.001), both effects replicating at each timepoint. Critically, the interviewer’s within-speaker coherence was reduced during conversations with patients ( d = −0.33, p =.016), indicating that the disruption extends beyond the patient to the interaction itself. Register divergence tracked impoverished thinking and synchrony tracked disorganized thinking (both FDR-corrected q =.038). Group differences were persistent at 12 months, indicating a partially stable profile. Conclusions Conversational alignment in psychosis reveals a dyadic failure of semantic coordination that destabilizes the interviewing clinician’s coherence even when patient narrative continuity is preserved. These transcript-derived alignment metrics offer a scalable approach to quantifying interpersonal communicative function from routine clinical encounters.