Restoring Trust for People With Psychosis Through Psychotherapy.

ABSTRACT: Mistrust is a significant problem for people with psychosis and can interfere with their capacity to engage in psychosocial treatment. In this article, the developmental trajectory of mistrust is outlined, including the impact that attachment disruption, childhood trauma, attributional biases, internalized stigma, and discrimination can have on the person's capacity to form trusting bonds with others. After this review, three elements are described that may allow for the restoration of trust: the therapist's openness to understanding the patient's experience and agenda for therapy, the therapist's effort to honestly disclose their thoughts to encourage dialogue and mutual reflection, and therapist's attempt to promote metacognition through helping the patient develop more complex representations of the minds of others. These elements are framed in the context of metacognitive reflection and insight therapy, an integrative therapy that is well suited to address mistrust through its explicit focus on metacognition and intersubjectivity.

Psychotherapy on an Acute Psychiatric Ward: Preliminary Findings From a Controlled Study.

This study investigated the efficacy of psychotherapy during hospitalization on an acute psychiatric ward. A controlled trial was conducted to assess the effects of Metacognitive Reflection and Insight Therapy (MERIT) upon metacognition and psychiatric symptoms. Data from 40 inpatient women were analysed. Findings included significant interaction effects between group (intervention or control group) and time (preintervention and postintervention) in regard to the metacognitive abilities and general psychiatric symptoms. Participating in MERIT seems to improve one's ability to use reflective knowledge to cope with psychological challenges and to improve symptomatology level.

The evolving role of the pharmacist for individuals with serious mental illness.

Adults with serious mental illness such as schizophrenia, bipolar disorder, or severe depression encounter many barriers in receiving appropriate health care services and are at a markedly increased risk of premature mortality. A range of clinical pharmacist roles in community mental health may help offset the increasing issues related to access to care and contribute to recovery-oriented systems of care for individuals with serious mental illness. In this commentary, we offer a description of one such model operationalized within a large community mental health center. Clinical pharmacists provide substantial contributions toward optimizing care for individuals with serious mental illness through medication therapy management, cardiovascular risk reduction, and various other interventions to help positively impact the health disparity these individuals face.

Disturbances in Self-Experience in Schizophrenia: Metacognition and the Development of an Integrative Recovery-Oriented Individual Psychotherapy.

BACKGROUND/AIMS: Disturbances in first person experience is a broadly noted feature of schizophrenia, which cannot be reduced to the expression of psychopathology. Yet, though categorically linked with profound suffering, these disturbances are often ignored by most contemporary treatment models. METHODS: In this paper, we present a model, which suggests that deficits in metacognition and their later resolution parsimoniously explain the development of self-disturbance and clarify how persons can later recover. We define "metacognition" as processes integral to the availability of a sense of self and others within the flow of life and report research suggesting its contribution to schizophrenia and link to self-disturbance. RESULTS: We describe a newly emerging integrative form of psychotherapy, Metacognitive Reflection and Insight Therapy (MERIT), designed to target metacognition and enhance the recovery of healthy self-experience. We describe eight measurable core elements that allow MERIT to be operationalized and discuss about how to address disturbances in self-experience. CONCLUSIONS: We detail research that provides evidence of the feasibility, acceptability, and effectiveness of MERIT across a broad range of patients, including those who might not otherwise be offered psychotherapy. MERIT represents one form of psychotherapy that may address self-disorders among adults with schizophrenia.

A pharmacist-managed cardiovascular risk-reduction clinic for individuals experiencing serious mental illness.

OBJECTIVES: This retrospective analysis sought to: (1) characterize a cardiovascular risk-reduction clinic (CVRRC) patient population with serious mental illness (SMI); (2) analyze clinical outcomes of CVRRC patients over a 2-year period; and (3) compare outcomes for individuals prescribed different antipsychotic treatments in the CVRRC patient population over a 2-year period. EVALUATION METHODS: In 2016, A pharmacist-managed CVRRC was implemented within a primary care clinic for patients with SMI. The CVRRC operates under a collaborative practice agreement allowing the pharmacist to initiate and change medications and order laboratory tests. Baseline data collected included demographic information, referring provider, tobacco use, and 10-year atherosclerotic cardiovascular disease risk. Data collected at subsequent visits included date of visit, A1C, estimated average glucose (eAG), blood pressure, weight, body mass index, low-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol, statin and dose, tobacco use, amount smoked, and current antipsychotic treatment. Number of times that treatment for diabetes was initiated or intensified by the pharmacist or primary care provider was also collected. IMPACT OF INNOVATION: A total of 101 patients were referred to the CVRRC over the 2-year period. Of these, 81 (80.2%) had at least 1 subsequent visit and were included in the A1C analysis. CVRRC patients had a statistically significant improvement in A1C over time. Mean A1C decreased by an increment of 0.06% for each month increase in follow-up time (P < 0.0001). There was no significant difference in A1C values between patients on different antipsychotic treatments (P = 0.74). CONCLUSION: The pharmacist-managed CVRRC demonstrated beneficial outcomes for individuals diagnosed with diabetes and SMI. Results provide promising evidence supporting future larger studies to confirm these findings. Considering the morbidity and mortality disparities for individuals with SMI, health care organizations should consider similar models to improve diabetes outcomes.

Supervision in the Psychotherapy of Schizophrenia: Awareness of and Mutual Reflection upon Fragmentation.

Historical and newly emerging models of schizophrenia suggest it is a disorder characterized by the fragmentation of the experience of the self and the world, leading to the interruption of how a unique life is unfolding in the world. It has been proposed that psychotherapy might therefore promote recovery by facilitating the development of a greater ability to integrate information about the self and others. In this paper we explore how the supervision of a metacognitively-oriented psychotherapy can assist therapists to experience and conceptualize fragmentation within sessions, join patients in the gradual process of making sense of their psychiatric problems and life challenges, and ultimately envision and achieve recovery. Common challenges and responses within supervision are described and discussed.

Application of Integrative Metacognitive Psychotherapy for Serious Mental Illness.

Recovery for many people with serious mental illness is more than symptom remission or attainment of certain concrete milestones. It can also involve recapturing a previously lost coherent and cohesive sense of self. The authors review several case studies of integrative metacognitive psychotherapy offered to adults with broadly differing clinical presentations. In all the cases, patients demonstrated significant subjective gains and objective improvements-for example, in negative symptoms, in substance use, and in overcoming a history of childhood sexual abuse. By applying this method to various problems-issues consistent with the realities faced in actual clinics-the authors explore how integrative metacognitive psychotherapy is able to address more subjective aspects of recovery by stimulating gains in the experience of agency that lead to the development of more cohesive self-experience, regardless of objective markers of recovery.

Emergence of psychotic content in psychotherapy: An exploratory qualitative analysis of content, process, and therapist variables in a single case study.

OBJECTIVE: Emerging integrative metacognitive therapies for schizophrenia seek to promote subjective aspects of recovery. Beyond symptom remission, they are concerned with shared meaning-making and intersubjective processes. It is unclear, however, how such therapies should understand and respond to psychotic content that threatens meaning-making in therapeutic contexts. Accordingly, we sought to understand what factors precede and potentially trigger psychotic content within psychotherapy and what aids in resolution and return to meaning-making. METHOD: Forty-eight transcripts from a single psychotherapy case were analyzed with thematic analysis. Passages of delusional or disorganized content were identified and themes present prior to the emergence and resolution of such material were identified and coded. RESULTS: Themes that preceded the emergence of psychotic content varied across early, middle, and late phases of therapy. Material related to the patient's experience of inadequacy and potential vulnerability, therapist setting boundaries within the therapeutic relationship and making challenges appeared to trigger psychotic content, especially early in treatment. CONCLUSIONS: Psychotic content may emerge in session following identifiable antecedents which change over phases of therapy. Attending to psychotic content by assuming a non-hierarchical stance and not dismissing psychotic content may aid in maintaining intersubjectivity and support patient's movements toward recovery in integrative metacognitive therapies.

Clinical Application of Patient-Centered Diabetes Care for People With Serious Mental Illness.

IN BRIEF Patients with serious mental illness (SMI) have markedly higher mortality rates than those without SMI. A large portion of this disparity is explained by higher rates of diabetes and cardiovascular illness, highlighting the need for people with diabetes and SMI to have access to the highest quality diabetes care. This article applies principles of patient-centered diabetes care to those with SMI, exploring a novel approach to diabetes care embedded within a community mental health setting.

The Role of Interpersonal Connection, Personal Narrative, and Metacognition in Integrative Psychotherapy for Schizophrenia: A Case Report.

The recovery movement has not only challenged traditional pessimism regarding schizophrenia but also presented opportunities for the possibilities for psychotherapy for people with the disorder. Though in the past psychotherapy models were often pitted against one another, recently there have been emergent reports of a range of integrative models sharing an emphasis on recovery and a number of conceptual elements. These shared elements include attention to the importance of interpersonal processes, personal narrative, and metacognition, with interest in their role in not only the disorder but also the processes by which people pursue recovery. This article explores one application of this framework in the psychotherapy of a woman with prolonged experience of schizophrenia and significant functional impairments.

Metacognitive capacity as a predictor of insight in first-episode psychosis.

Impaired insight is common in the first episode of psychosis (FEP). Although considerable research has examined the factors that are associated with impaired insight in chronic psychosis, less is known about the factors that underlie and sustain poor insight in FEP. Impaired metacognition, or the ability to form integrated representations of self and others, is a promising potential contributor to poor insight in FEP. To explore this possibility, the authors assessed insight and metacognition in 40 individuals with FEP and then examined the relationship between these areas and social cognition domains, neurocognitive domains, and psychotic symptoms. Correlation analyses revealed that improved insight was associated with higher metacognition, better vocabulary and Theory of Mind scores, and fewer symptoms. The domain of metacognitive mastery also predicted clinical insight. Results support the need to develop an integrative therapeutic approach focused on improving metacognition, hence addressing poor insight in FEP.

Metacognitive Deficits in Schizophrenia: Presence and Associations With Psychosocial Outcomes.

Early formulations of schizophrenia suggested that the disorder involves a loss of ability to form integrated ideas about oneself, others, and the world, resulting in reductions in complex goal-directed behaviors. Exploring this position, the current review describes evidence that persons with schizophrenia experience decrements in their ability to form complex ideas about themselves and to ultimately use that knowledge to respond to psychological and social challenges. Studies are detailed that find greater levels of these impairments, defined as metacognitive deficits, in persons with schizophrenia in both early and later phases of illness as compared with other clinical and community groups. Furthermore, studies linking metacognitive deficits with poorer psychosocial functioning and other variables closely linked to outcomes are summarized. Clinical implications are also discussed.

Allowing for Psychosis to be Approachable and Understandable as a Human Experience: A Role for the Humanities in Psychotherapy Supervision.

Psychiatry and related mental health fields, in particular psychotherapy, have a long history of close ties with the humanities. That bond has weakened, however, over the last few decades as medicalized views of mental health and treatment have emerged. In this paper, we explore the potential of the reintroduction of the humanities, specifically novels and related literary genre, into the supervision of student clinicians working with clients who have psychosis. We believe that incorporation of novels and related literary genre into supervision can lead to unique and deepened understanding of the experience of psychosis, and can create an opportunity for a working therapeutic alliance. The potential mechanisms that create these unique opportunities to understand psychopathology are explored, and considerations for the implications for treatment, training, and future research are presented.

Literature as an exploration of the phenomenology of schizophrenia: disorder and recovery in Denis Johnson's Jesus' Son.

When read as a fictional psychosis narrative, Jesus' Son, a collection of short stories by Denis Johnson, reveals important elements of the phenomenology of schizophrenia and recovery. It is possible that Jesus' Son, as a work of fiction, may be able to uniquely add depth and nuance to an understanding of the phenomenology of schizophrenia involving a state of psychological fragmentation, an ever-changing interpersonal field and a loss of personal agency. In addition, by following the protagonist in Jesus' Son as he begins to resolve some of his difficulties, the book also offers an individualised account of recovery. The authors detail how the book reveals these insights about schizophrenia and recovery and suggest that these elements are intertwined in such a manner that leads to a profound disruption of self-experience, characterised by a collapse of metacognitive processes. Jesus' Son may add depth to our understanding of the subjective experience of schizophrenia and recovery, and also may serve as one example in which the study of humanities offers an opportunity to explore the human elements in the most profound forms of suffering.

A Recovery-Oriented Approach: Application of Metacognitive Reflection and Insight Therapy (MERIT) for Youth with Clinical High Risk (CHR) for Psychosis.

Clinical High Risk for psychosis (CHR) refers to a phase of heightened risk for developing overt psychosis. CHR often emerges during adolescence or early adulthood. CHR has been identified as a group to target for intervention, with the hope that early intervention can both stave off prolonged suffering and intervene before mental health challenges become part of an individual's identity. However, there are few treatment modalities that can address some of the specific needs of CHR. Metacognitive Reflection and Insight Therapy (MERIT) is an integrative psychotherapy that can be applied to the CHR population. MERIT offers unique advantages to working with the CHR population as it aims to improve self-direction and recovery through stimulation of metacognitive capacity, a phenomenon that has been associated with recovery. This paper explores unique aspects of the CHR population and how MERIT can address barriers to recovery for individuals experiencing psychosis-like symptoms. Several case examples and a clinical vignette using MERIT to support patients with CHR are offered to exemplify this approach. MERIT offers a way to assist persons with CHR to address barriers to their personal recovery and to develop nuanced understandings of ways to master challenges.

Reading fiction together to support reflective practice and recovery in serious mental illness: The value of book club.

OBJECTIVE: To illustrate the value of reading fiction as a group supervision practice focused on supporting recovery-oriented psychotherapy for individuals experiencing serious mental illness (SMI). METHOD: Detailed practical description of the practice and conceptual analysis of the proposed value of using fiction as a group supervision method. FINDINGS: Authors suggest that the supervisory practice is a novel component of clinical supervision, and offers value in its ability to promote reflective practice, to establish intersubjectivity among peers and supervisory relationships, and may serve for some to counter risks of clinician burnout. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Participating in a book club that reads fiction as an adjunctive experience to supervision can promote recovery-oriented psychotherapy in four key ways: including its promotion of reflection on self, patients, and the experience of therapy for psychosis, its promotion of reflection on recovery and barriers to recovery, its ability to offer an experiential model of intersubjectivity, and its value in supporting peer consultation and helping offset clinician burnout. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Supervision of psychotherapy for psychosis: A meaning-making approach.

Despite its importance in the provision of mental health treatment, the availability of high-quality clinical supervision faces numerous threats in the public sector. Access to high-quality supervision may be especially important for therapists providing services to persons with psychosis. Here, we detail one supervisory approach that has been developed with these considerations in mind; namely, the supervision approach associated with the recovery-oriented integrative therapy metacognitive reflection and insight therapy. We detail three aspects of this approach that have broad appeal and could be easily incorporated into other psychotherapy approaches which include (a) reflecting with supervisees about their experience of the patient, themselves, and the therapeutic relationship, (b) helping supervisees respond to patients' pain and fragmentation with interventions that promote challenge and joint meaning-making, and (c) dealing with threats to this process from both internal pressures within supervisees as well as those posed externally from their agencies. Limitations of this approach and future directions are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Integrating Loss and Processing Grief in Psychotherapy of Psychosis.

Objective: While recovery from psychosis is possible, recovery is a multidimensional construct driven by various factors. One relevant factor to recovery from psychosis that has often been overlooked in the psychotherapy literature is the importance of facing loss and processing grief in relation to psychosis. Methods: A review of the existing empirical literature on grief associated with psychosis was conducted. Clinicians with significant therapeutic experience working with persons with psychosis reviewed cases to examine the losses the patients had suffered and how they responded to these losses. The clinicians considered essential principles that are relevant when helping patients with psychosis integrate loss and process grief. Results: Persons who have experienced psychosis often experience the loss of role functioning, interpersonal relationships, cognition, and self-concept. However, when these losses are not fully integrated into the person's identity, it can result in either more losses due to denial and metacognitive impairments or increased hopelessness and depression due to internalized stigma. Five elements in psychotherapy of psychosis were identified that can facilitate the integration of loss and processing of grief: understand the personal experience of the psychotic episode, attend to feelings of grief and the primary loss, explore the meaning of psychotic symptoms and identity implications, integrate psychotic vulnerabilities into the sense of self, and foster realistic hope in the face of an uncertain future. Conclusion: Psychotherapy can enable persons with psychosis to make meaning of their losses, process their grief, integrate their psychotic vulnerability into their sense of self, and develop realistic hope.

Metacognition and social cognition in schizophrenia: stability and relationship to concurrent and prospective symptom assessments.

OBJECTIVE: Schizophrenia has been linked with deficits in the ability to form complex representations about oneself and others. Less clear is whether these deficits are stable over time, and whether they are related to symptoms. METHOD: We assessed metacognition capacity, affect recognition, executive function, and symptoms at baseline and 6 months later for 49 adults with schizophrenia. RESULTS: Paired t tests revealed assessments of metacognition and affect recognition were stable across measurements points. Metacognition was related to concurrent assessments of positive, negative and disorganized symptoms. Multiple regressions revealed metacognition was related to prospective assessments of negative symptoms after controlling for baseline negative symptoms and executive function. CONCLUSIONS: Metacognitive deficits are a stable feature of schizophrenia related with negative symptoms.

Comparing narrative-informed occupational therapy in adult outpatient mental health to treatment as usual: A quasi-experimental feasibility study with preliminary treatment outcomes.

This paper describes implementation of a narrative-informed occupation-based service in an outpatient community mental health setting that addressed several gaps, including 1) the need for outcome data on occupational therapy in this setting; 2) an ongoing mental health provider shortage; and 3) a need for innovative approaches to supporting mental health. We found a significant improvement from baseline to post-intervention in occupational participation, and dose of occupational therapy was significantly related to improvements in the areas of roles, habits, values, long-term goals, social environment, and readiness for change. This study suggests future, larger effectiveness studies of narrative-informed occupation-based interventions delivered by occupational therapists in outpatient community mental health are warranted.