Designing and implementing a physical exercise intervention for people with first episode psychosis using experience-based co-design: A pilot study from Chennai, India.

BACKGROUND: Physical exercise can improve outcomes for people with first-episode psychosis (FEP). Co-designing physical exercise interventions with end users has the potential to enhance their acceptability, feasibility, and long-term viability. This study's objective was to use experience-based co-design (EBCD) methodology to develop a physical exercise intervention for FEP, and pilot test it. METHODS: The study was conducted at the Schizophrenia Research Foundation's FEP program in Chennai, India. Participants(N=36) were individuals with FEP and their caregivers, mental health professionals (MHPs, and physical training experts. EBCD methodology included one-to-one interviews, focus group discussions, joint conferences, and co-design workshops. Two instructional videos were developed. Twelve FEP patients engaged in physical exercise with help of the videos over three months. They were followed up through weekly phone calls and in-person interviews to capture data on regularity, frequency, location of exercise, and comfort levels. RESULTS: Several touch points emerged from the interviews, focus groups, and joint meetings including lack of motivation, knowledge about physical exercise; differing perspectives about physical exercise; limited resource, and time constraints. Two instructional videos demonstrating activities for participants incorporated strategies that addressed these touch points. Pilot data indicated that participants engaged with the physical exercise intervention over 3 months. CONCLUSION: This was the first study to use co-design methodology to design a physical exercise intervention for first-episode psychosis. The intervention may have therefore been responsive to stakeholder needs and preferences. Results of this study highlight the potential of co-design in designing and adapting interventions. There is need for rigorous testing with larger samples.

Factors associated with recovery during schizophrenia and related disorders: A review of meta-analysis.

BACKGROUND: The spectrum of schizophrenia disorders (SSD) is a severe mental disorder. It is one of the main medical causes of disability that generates high health and social costs. OBJECTIVE: To analyze the factors associated with clinical recovery (CR) (symptomatic remission-SR and functional recovery-FR) and personal recovery (PR) in people diagnosed with SSD. METHODS: 14 meta-analyses focused on recovery were reviewed following the PRISMA model statements. 95 % of CI was established. RESULTS: Shorter Duration of Untreated Psychosis (Zr = 0.24, [0.17, 0.30]) and total Duration of Untreated Illness (Zr = 0.34, [0.20, 0.48]) were related to greater SR and general functioning, respectively. Resilience was the variable with the greatest effect on FR (Zr = 0.67, [0.63, 0.71]). Premorbid adjustment (Zr = 0.34, [0.18, 0.49]) and physical intervention (Zr = 0.71, [0.55, 0.86]) had the greatest effect on occupational and social functioning, respectively. Less severe affective symptoms were related to greater PR (Zr = 0.46, [0.42, 0.50]). There are differences between affective SR and the other types of SR (Zr(SR-A - SR-) = 0.13, Qb = 6.51, p = 0.011), (Zr(SR-A - SR+) = 0.20, Qb = 8.52, p = 0.004), (Zr(SR-A - SR) = 0.18, Qb = 19.29, p = 0.0001). In all, resilience was associated with greater recovery (Zr = 0.67, [0.53, 0.80]), with the global effect being greater on PR than on CR (Zr(PR-CR) = 0.07, Qb = 3.45, p = 0.05). CONCLUSIONS: Resilience was the variable most strongly associated with recovery. Symptomatic or functional improvement obtained less statistical weight.

Systematic Review and Meta-analysis of Exercise Interventions for Psychotic Disorders: The Impact of Exercise Intensity, Mindfulness Components, and Other Moderators on Symptoms, Functioning, and Cardiometabolic Health.

BACKGROUND AND HYPOTHESIS: Exercise therapy has been shown to be an effective complementary treatment for patients with psychotic disorders. However, the specific impacts of different training modalities remain poorly understood. This article aims to quantitatively review the moderating influence of different exercise modalities, hypothesizing that higher exercise intensity as well as utilization of mindfulness-based exercise (MBE) components, will improve intervention outcomes. STUDY DESIGN: PubMed, Web of Science, and PsycINFO were searched from 2010 to March 2022 for randomized controlled trials investigating exercise interventions in patients with psychotic disorders (preregistration: https://doi.org/10.17605/OSF.IO/J8QNS). Outcomes considered were positive/negative symptoms, Positive and Negative Syndrome Scale (PANSS) General Psychopathology/Total scores, depressive symptoms, psychosocial functioning, quality of life, cardiorespiratory fitness, and body mass index. Separate meta-analyses, including moderator analyses, were performed to evaluate the moderating influence of different training modalities. STUDY RESULTS: Of 6653 studies, 40 (n = 2111 patients) were included in the meta-analysis. The effects of moderate-intensity exercise exceed low-intensity approaches for PANSS Total scores (P = .02) and depressive symptoms (P = .04). The presence of MBE components was associated with improvements in positive symptoms (P = .04) and PANSS General Psychopathology subscores (P = .04) but also with higher error and between-study heterogeneity. Our analysis also shows improved intervention effects on depression in younger patients (P = .012) and improved psychosocial functioning scores following more frequent sessions (P < .01). CONCLUSIONS: A minimum of moderate intensity should be considered. More frequent training sessions per week also seem to be beneficial. While adding mindfulness elements is promising, it increases heterogeneity and requires caution in terms of generalization.

Social cognition and social problem solving skills training to improve job functioning and tenure in veterans with psychotic disorders.

OBJECTIVE: Veterans with psychotic disorders often experience employment difficulties. Job tenure is highly variable with shorter tenure frequently tied to interpersonal difficulties in the workplace. The present study sought to address this problem by examining the efficacy of social cognition skills training (SCST) and social problem solving skills training (SPSST) interventions, implemented sequentially, and added to usual VA employment services (augmented vocational rehabilitation [VR]). METHOD: Participants were 91 Veterans with schizophrenia and other psychotic disorders who were recently enrolled in one of three types of VA employment services (incentive therapy, transitional work, supported employment), and randomized 1:1 to augmented VR versus control VR. Training for the augmented VR group included 12 weeks of SCST plus 6 weeks of work-related SPSST; training for the control VR group included a control intervention (symptom management training) matched in instructional format and length of training to the SCST and SPSST interventions. All participants received baseline and posttraining measures of social cognition. For those who got jobs, the primary work outcome measures were social skills work behavior and job tenure. RESULTS: Results showed a significant group x time interaction favoring the augmented VR group on measures of social cognition and social skills work behavior, but there were no significant differences in job tenure. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The findings for workplace social skills support a promising new direction for enhancing work outcomes in this population; the null effect on job tenure may have been due to high job retention rates across the three types of employment service programs. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Durable Cognitive Gains and Symptom Improvement Are Observed in Individuals With Recent-Onset Schizophrenia 6 Months After a Randomized Trial of Auditory Training Completed Remotely.

OBJECTIVE: Cognitive impairment in schizophrenia predicts functional outcomes and is largely unresponsive to pharmacology or psychotherapy; it is thus a critical unmet treatment need. This article presents the impact of remotely completed, intensive, targeted auditory training (AT) vs control condition computer games (CG) in a double-blind randomized trial in young adults with recent-onset schizophrenia. METHOD: Participants (N = 147) were assessed for cognition, symptoms, and functioning at baseline, post-intervention, and at 6-month follow-up. All participants were provided with laptop computers and were instructed to complete 40 hours remotely of training or computer games. An intent-to-treat analysis (N = 145) was performed using linear mixed models with time modeled as a continuous variable. Planned contrasts tested the change from baseline to post-training, baseline to 6-month follow-up, and post-training to 6-month follow-up. RESULTS: Global Cognition, which had improved in the AT group relative to the CG group at post-training, showed durable gains at 6-month follow-up in an omnibus group-by-time interaction test (F(1,179) = 4.80, P = .030), as did Problem-Solving (F(1,179) = 5.13, P = .025), and Speed of Processing improved at trend level significance (F(1,170) = 3.80, P = .053). Furthermore, the AT group showed significantly greater improvement than the CG group in positive symptoms (F(1,179) = 4.06, P = .045). CONCLUSIONS: These results provide the first evidence of durable cognitive gains and symptom improvement at follow-up of cognitive training (CT) in early schizophrenia completed independently and remotely. While functioning did not show significant improvement, these findings suggest that intensive targeted CT of auditory processing is a promising component of early intervention to promote recovery from psychosis.

Effects of SlowMo, a Blended Digital Therapy Targeting Reasoning, on Paranoia Among People With Psychosis: A Randomized Clinical Trial.

Importance: Persistent paranoia is common among patients with psychosis. Cognitive-behavioral therapy for psychosis can be effective. However, challenges in engagement and effectiveness remain. Objective: To investigate the effects on paranoia and mechanisms of action of SlowMo, a digitally supported reasoning intervention, plus usual care compared with usual care only. Design, Setting, and Participants: This parallel-arm, assessor-blinded, randomized clinical trial recruited participants at UK community health services from May 1, 2017, to May 14, 2019. Eligible participants consisted of a referral sample with schizophrenia-spectrum psychosis and distressing, persistent (≥3 months) paranoia. Interventions: Individuals were randomized 1:1 to SlowMo, consisting of 8 digitally supported face-to-face sessions and a mobile app, plus usual care (n = 181) and usual care only (n = 181). Main Outcomes and Measures: The primary outcome was paranoia, measured by the Green et al Paranoid Thoughts Scale (GPTS) total score at 24 weeks. Secondary outcomes included GPTS total score at 12 weeks and GPTS Part A (reference) and Part B (persecutory) scores, the Psychotic Symptom Rating Scales (PSYRATS Delusion subscale), reasoning (belief flexibility, possibility of being mistaken [Maudsley Assessment of Delusions, rated 0%-100%]), and jumping to conclusions (Beads Task). Results: A total of 361 participants were included in intention-to-treat analysis, of whom 252 (69.8%) were male and 249 (69.0%) were White; the mean (SD) age was 42.6 (11.6) years. At 24 weeks, 332 participants (92.0%) provided primary outcome data. Of 181 participants in the SlowMo group, 145 (80.1%) completed therapy. SlowMo plus usual care was not associated with greater reductions than usual care in GPTS total score at 24 weeks (Cohen d, 0.20; 95% CI, -0.02 to 0.40; P = .06). There were significant effects on secondary paranoia outcomes at 12 weeks, including GPTS total score (Cohen d, 0.30; 95% CI, 0.09-0.51; P = .005), Part A score (Cohen d, 0.22; 95% CI, 0.06-0.39; P = .009), and Part B score (Cohen d, 0.32; 95% CI, 0.08-0.56; P = .009), and at 24 weeks, including Part B score (Cohen d, 0.25; 95% CI, 0.01-0.49; P = .04) but not Part A score (Cohen d, 0.12; 95% CI, -0.05 to 0.28; P = .18). Improvements were observed in an observer-rated measure of persecutory delusions (PSYRATS delusion) at 12 weeks (Cohen d, 0.47; 95% CI, 0.17-0.78; P = .002) and 24 weeks (Cohen d, 0.50; 95% CI, 0.20-0.80; P = .001) and belief flexibility at 12 weeks (Cohen d, 0.29; 95% CI, 0.09-0.49; P = .004) and 24 weeks (Cohen d, 0.28; 95% CI, 0.08-0.49; P = .005). There were no significant effects on jumping to conclusions. Improved belief flexibility and worry mediated paranoia change (range mediated, 36%-56%). Conclusions and Relevance: SlowMo did not demonstrate significant improvements in the primary measure of paranoia at 24 weeks; however, a beneficial effect of SlowMo on paranoia was indicated by the results on the primary measure at an earlier point and on observer-rated paranoia and self-reported persecution at 12 and 24 weeks. Further work to optimize SlowMo's effects is warranted. Trial Registration: isrctn.org Identifier: ISRCTN 32448671.

Clinical management of individuals with Intellectual Disability: The outbreak of Covid-19 pandemic as experienced in a clinical and research center Research in Developmental Disabilities.

During the COVID-19 pandemic, the Oasi Research Institute of Troina (Italy) became an important hotbed for infection; in fact, 109 patients with different levels of Intellectual Disability (ID) tested positive for COVID-19. The procedures and interventions put in place at the Oasi Research Institute due to the COVID-19 pandemic are exhaustively reported in this paper. The description of the clinical procedures as well as remote/in person psychological support services provided to people with ID and their families are here divided into three different sections: Phase I (or Acute phase), Phase II (or Activity planning), and Phase III (or Activity consolidation). In each section, the main psycho-pathological characteristics of patients, the reactions of family members and the multidisciplinary interventions put in place are also described.

Homeless men with psychosis are spending more time shelterless.

OBJECTIVE: The objective of this study was to determine if homeless men with psychosis in central Melbourne have spent a greater proportion of the past 12 months in homeless settings as compared with the same group 15 years previously. METHOD: A 12-month accommodation history was collected from all men with psychosis assessed by a homeless outreach mental health team over a 12-month period commencing 2018 and compared with data from 2006. RESULTS: Between 2006 and 2018, the percentage of time spent homeless in the previous 12 months rose from 50% to 80% (p = 0.0001). The mean time spent shelterless increased from 72 days to 149 days (p = 0.0001). CONCLUSIONS: The amount of time spent homeless has increased in men with psychosis assessed in central Melbourne. This finding suggests that men with psychosis are becoming increasingly entrenched in homeless settings. Addressing this trend requires an increased emphasis on assertive outreach, greater access to acute inpatient and long-term rehabilitation units, and more low cost affordable housing, including housing first facilities.

Neural changes following a body-oriented resilience therapy with elements of kickboxing for individuals with a psychotic disorder: a randomized controlled trial.

Individuals with a psychotic disorder are at an increased risk of becoming the victim of a crime. A body-oriented resilience therapy (BEATVIC) aimed at preventing victimization by addressing putatively underlying factors was developed. One of these factors is social cognition, particularly facial affect processing. The current study investigated neural effects of BEATVIC on facial affect processing using two face processing tasks. Participants were randomized to either BEATVIC or a 'Befriending' control group. Twenty-seven patients completed an Emotional Faces task and the Wall of Faces task during fMRI, pre- and post-intervention. General linear model analyses yielded no differences between groups over time. Independent component analyses revealed increased activation of the salience network to angry and fearful faces in BEATVIC compared to Befriending. Increased activation of the salience network may suggest an increased alertness for potentially dangerous faces.

Dissecting the functional outcomes of first episode schizophrenia spectrum disorders: a 10-year follow-up study in the PAFIP cohort.

BACKGROUND: The aim of the current study was to examine the heterogeneity of functional outcomes in first episode psychosis (FEP) patients and related clinical, neurocognitive and sociodemographic factors using a cluster analytic approach. METHOD: A large sample of FEP patients (N = 209) was functionally reassessed 10 years after the first contact with an early intervention service. Multiple baseline, 3-year and 10-year follow-up variables were explored. RESULTS: The cluster analysis emphasized the existence of six independent clusters of functioning: one cluster was normal overall (42.16%), two clusters showed moderate interpersonal (9.63%) or instrumental (12.65%) deficits, two clusters showed more severe interpersonal (12.05%) or interpersonal and instrumental (13.85%) deficits and there was a significantly overall impaired cluster (9.63%). Cluster comparisons showed that several baseline and follow-up factors were differentially involved in functional outcomes. CONCLUSIONS: The current study demonstrated that distinct clusters of functioning in FEP patients can be identified. The fact that a variety of profiles was observed contributes to a better understanding of the nature of the heterogeneity characterizing FEP patients and has clinical implications for developing individualized treatment plans.

Characteristics associated with self-reported medication adherence in persons with psychosis referred to psychosocial rehabilitation centers.

The aim of the present study was to explore the characteristics of psychotropic treatment and of psychosocial functioning associated with self-reported medication adherence in persons with psychosis engaged in rehabilitation. The study was performed in the REHABase cohort including persons referred to a French network of psychosocial rehabilitation centers. Treatment adherence was assessed using the Medication Adherence Rating Scale (MARS). The associations between MARS score (categorized as "low" < 7 vs. "high" ≥ 7) and functioning or psychotropic treatment characteristics were explored using multivariate analyses in 326 participants with schizophrenia spectrum disorders. Regarding psychotropic treatment, high anticholinergic load was the only characteristic associated with poor medication adherence (adjusted OR, aOR 1.98, 95% CI 1.07-3.66). Regarding functioning measures, participants with poor medication adherence were more likely to present with lower stage of recovery (aOR 2.38, 95% CI 1.31-4.32), poor quality of life (aOR 2.17, 95% CI 1.27-3.71), mental well-being (aOR 1.68, 95% CI 1.03-2.72) and self-esteem (aOR 1.74, 95% CI 1.05-2.87), and higher internalized stigma (aOR 1.88, 95% CI 1.09-3.23). Self-reported poor medication adherence is a marker of poor functioning in persons with psychosis. The MARS is a quick and simple measure of adherence that may be helpful in clinical and rehabilitation settings to identify persons with specific rehabilitation needs.

COVID-19 Transmission in a Psychiatric Long-Term Care Rehabilitation Facility: An Observational Study.

OBJECTIVE: To report the clinical characteristics and transmission rate of coronavirus disease 2019 (COVID-19) in a community inpatient long-term care psychiatric rehabilitation facility designed for persons with serious mental illness to provide insight into transmission and symptom patterns and emerging testing protocols, as well as medical complications and prognosis. METHODS: This study examined a cohort of 54 residents of a long-term care psychiatric rehabilitation program from March to April 2020. Baseline demographics, clinical diagnoses, and vital signs were examined to look for statistical differences between positive versus negative severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) groups. During the early phase of the pandemic, the facility closely followed the local shelter-in-place order (starting March 19, 2020) and symptom-based testing. RESULTS: Of the residents, the primary psychiatric diagnoses were schizoaffective disorder: 28 (51.9%), schizophrenia: 21 (38.9%), bipolar I disorder: 3 (5.5%), and unspecified psychotic disorder: 2 (3.7%). Forty (74%) of 54 residents tested positive for SARS-COV-2, with a doubling time of 3.9 days. There were no statistical differences between the positive SARS-COV-2 versus negative groups for age or race/ethnicity. Psychiatric and medical conditions were not significantly associated with contracting SARS-COV-2, with the exception of obesity (n = 17 [43%] positive vs n = 12 [86%] negative, P = .01). Medical monitoring of vital signs and symptoms did not lead to earlier detection. All of the residents completely recovered, with the last resident no longer showing any symptoms 24 days from the index case. CONCLUSION: Research is needed to determine optimal strategies for long-term care mental health settings that incorporate frequent testing and personal protective equipment use to prevent rapid transmission of SARS-COV-2.

Personalized cognitive remediation therapy to facilitate return to work or to school in recent-onset psychosis.

Cognitive deficits are barriers to job acquisition or return to school, and can be reduced through Cognitive remediation therapy (CRT). The main goal of this multiple case study was to investigate the effect of personalized CRT on occupational status in three participants with a recent-onset psychosis. Two cases improved their occupational status at post-treatment, and showed improvements in cognitive, psychological, and/or clinical variables. This study suggests that personalized CRT may facilitate job acquisition or return to school. However, the different pathways showed by our cases indicate that personalized CRT may influence occupational status through multiple mechanisms, underlining the relevance of treatment personalization.

Understanding the experience of initiating community-based group physical activity by people with serious mental illness: A systematic review using a meta-ethnographic approach.

BACKGROUND: People living with serious mental illness (SMI) experience debilitating symptoms that worsen their physical health and quality of life. Regular physical activity (PA) may bring symptomatic improvements and enhance wellbeing. When undertaken in community-based group settings, PA may yield additional benefits such as reduced isolation. Initiating PA can be difficult for people with SMI, so PA engagement is commonly low. Designing acceptable and effective PA programs requires a better understanding of the lived experiences of PA initiation among people with SMI. METHODS: This systematic review of qualitative studies used the meta-ethnography approach by Noblit and Hare (1988). Electronic databases were searched from inception to November 2017. Eligible studies used qualitative methodology; involved adults (≥18 years) with schizophrenia, bipolar affective disorder, major depressive disorder, or psychosis; reported community-based group PA; and captured the experience of PA initiation, including key features of social support. Study selection and quality assessment were performed by four reviewers. RESULTS: Sixteen studies were included in the review. We identified a "journey" that depicted a long sequence of phases involved in initiating PA. The journey demonstrated the thought processes, expectations, barriers, and support needs of people with SMI. In particular, social support from a trusted source played an important role in getting people to the activity, both physically and emotionally. DISCUSSION: The journey illustrated that initiation of PA for people with SMI is a long complex transition. This complex process needs to be understood before ongoing participation in PA can be addressed. Registration-The review was registered on the International Prospective Register of Systematic Reviews (PROSPERO) on 22/03/2017 (registration number CRD42017059948).

Cognitive strengths-based assessment and intervention in first-episode psychosis: A complementary approach to addressing functional recovery?

People who have experienced psychosis describe functional and personal recovery as a key goal of treatment. To date, the early, pervasive and influential role of cognitive impairments in functional recovery in psychosis has been predominantly addressed using approaches aiming to remediate clinically-defined cognitive deficits. Despite acceptance of the recovery and strengths-based model of care for first-episode psychosis (FEP), there has been minimal attention paid to the potential for strengths-based approaches to be extended to cognitive function. The purpose of this review is to present the case for supplementary strengths-based approaches to addressing cognition and functioning in FEP. In this review we appraise current approaches to addressing cognition in FEP that have primarily focused on remediating cognitive impairment, showing evidence for inconsistent engagement and generally small treatment effects. We describe the important role of psychological factors such as motivation and self-efficacy in mediating the relationship between cognitive performance and functional outcome, and draw on positive psychology and self-determination theory as models for potential application in relation to a cognitive-strengths paradigm. Our review supports the argument for complementing approaches for remediating cognitive deficits by applying strengths-based or positive psychology approaches to the domain of cognition as a promising avenue for further enhancing personal and functional recovery from FEP.

Results of a prospective, mixed methods study to assess feasibility, acceptability and effectiveness of TRIumPH (Treatment and Recovery In PsycHosis): an integrated care pathway for psychosis, compared to usual treatment.

OBJECTIVES: To evaluate whether a newly developed care pathway, Treatment and Recovery In PsycHosis (TRIumPH), is feasible, acceptable and effective in meeting National Institute of Health and Care Excellence (NICE) quality standards in a timely manner. METHODS: This is a pragmatic, non-randomised, prospective, mixed methods study comparing an implementation (TRIumPH) and comparator site (not implementing TRIumPH) across three cohorts to assess feasibility, acceptability and effectiveness of the integrated pathway. SETTING: Early intervention in psychosis (EIP) services at two National Health Service organisations in South of England. PARTICIPANTS: All patients accepted into EIP services between 1 June 2014 and 31 May 2017 were each followed up for 1 year within their respective cohorts. METHODOLOGY: Quantitative data consisted of routinely collected clinical data retrieved from patient records to assess whether the implementation of TRIumPH achieved better concordance to NICE standards. These included time to access services, physical health assessments, clinical outcomes based timeliness of delivery and acute data. The controlled trial has evaluated the effect of TRIumPH (Intervention) with Care As Usual (Comparator). Qualitative measures consisted of questionnaires, interviews and focus groups to assess acceptability and satisfaction. Outcome measures were compared within the baseline, year 1 and year 2 cohorts and between the two sites. Quantitative data were statistically analysed by comparing means and proportions. RESULTS: Time to assessment improved in the implementation site and remained within the target in comparator site. Meeting of quality standards increased substantially in the implementation site but was more variable and reached lower levels in the comparator site especially for physical health standards. Cognitive therapy for psychosis, family intervention and carer and employment support were all offered to a greater extent in the implementation site and uptake increased over the period. CONCLUSIONS: Pathway implementation generally led to greater improvements in achievement of access and quality standards compared with comparator site. TRIAL REGISTRATION NUMBER: UK Clinical Research Network Portfolio (19187).

Emergence of insight in psychotherapy for early psychosis: A qualitative analysis of a single case study.

OBJECTIVE: Engaging individuals experiencing early psychosis (EP) in mental health treatment is broadly recognized as a challenging endeavor, especially when persons with EP experience impaired insight or relative unawareness of the psychiatric challenges they face. With limited insight they may see little point to treatment and have difficulties forming an alliance with providers. Tackling the issues of poor insight in EP is further complicated by a lack of knowledge of the processes within psychosocial interventions that lead to improved insight. METHOD: To explore this, qualitative methods were used to identify content, process, and therapist factors that appeared before and seemed to support insight in a patient experiencing EP as well as the frequency with which insight and psychological problems emerged. The case examined was a 6-month psychotherapy from a pilot study examining the use of metacognitive reflection and insight therapy in EP. RESULTS: Five prominent codes were identified across 24 psychotherapy transcripts that appeared to support the development of insight: narrative details, interpersonal relationships, therapist curiosity, therapist support, and therapist challenges. These appear to have allowed for the emergence of psychological problems first and then finally insight into mental health needs. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Addressing metacognitive capacity in psychotherapy may allow persons with low insight to recognize psychological problems and then develop a complex idea about their psychiatric challenges. (PsycInfo Database Record (c) 2020 APA, all rights reserved).