Social Dysfunction in Psychosis Is More Than a Matter of Misperception: Advances From the Study of Metacognition.

Many with psychosis experience substantial difficulties forming and maintaining social bonds leading to persistent social alienation and a lack of a sense of membership in a larger community. While it is clear that social impairments in psychosis cannot be fully explained by symptoms or other traditional features of psychosis, the antecedents of disturbances in social function remain poorly understood. One recent model has proposed that deficits in social cognition may be a root cause of social dysfunction. In this model social relationships become untenable among persons diagnosed with psychosis when deficits in social cognition result in inaccurate ideas of what others feel, think or desire. While there is evidence to support the influence of social cognition upon social function, there are substantial limitations to this point of view. Many with psychosis have social impairments but not significant deficits in social cognition. First person and clinical accounts of the phenomenology of psychosis also do not suggest that persons with psychosis commonly experience making mistakes when trying to understand others. They report instead that intersubjectivity, or the formation of an intimate shared understanding of thoughts and emotions with others, has become extraordinarily difficult. In this paper we explore how research in metacognition in psychosis can transcend these limitations and address some of the ways in which intersubjectivity and more broadly social function is compromised in psychosis. Specifically, research will be reviewed on the relationship between social cognitive abilities and social function in psychosis, including measurement strategies and limits to its explanatory power, in particular with regard to challenges to intersubjectivity. Next, we present research on the integrated model of metacognition in psychosis and its relation to social function. We then discuss how this model might go beyond social cognitive models of social dysfunction in psychosis by describing how compromises in intersubjectivity occur as metacognitive deficits leave persons without an integrated sense of others' purposes, relative positions in the world, possibilities and personal complexities. We suggest that while social cognitive deficits may leave persons with inaccurate ideas about others, metacognitive deficits leave persons ill equipped to make broader sense of the situations in which people interact and this is what leaves them without a holistic sense of the other and what makes it difficult to know others, share experiences, and sustain relationships. The potential of developing clinical interventions focused on metacognition for promoting social recovery will finally be explored.

Narrative Identity, Metacognition, and Well-Being in Patients With Schizophrenia or HIV.

It has been proposed that schizophrenia reflects disturbances in personal identity, which include sense of personal agency, sense of belonging within a social group, and metacognition. Less is known about how these different processes are related to one another and to well-being outcomes. To study this, we measured themes of agency and communion in narrative identity in 29 individuals with schizophrenia and 29 individuals with HIV. All participants had previously been assessed on metacognitive abilities using the Indiana Psychiatric Illness Interview (IPII) and completed scales measuring hopelessness and self-esteem. For the present study, themes of agency and communion were coded from the IPII transcripts. Results indicated that participants with schizophrenia had lower levels of agency and communion compared with participants with HIV. More presence of agency and communion themes were related to better metacognitive abilities as well as less hopelessness and higher self-esteem across groups. Agency predicted variance in hopelessness after controlling for metacognitive abilities. The results suggest that although the construction of narrative identity may depend on metacognitive abilities, agency themes predict outcomes beyond metacognition.

Cognitive theory of mind in bipolar disorder: Comparisons with healthy controls and associations with function.

Cognitive forms of Theory of Mind (ToM) have been linked to social function in Bipolar Disorder (BD). To explore this social functioning was assessed with the GAF and cognitive ToM was assessed with the Hinting Task and the Picture Sequencing Task (PST) in 45 patients with BP and 45 healthy controls. As predicted, the BD group took longer to complete the PST. The BD group did not offer more incorrect responses to either cognitive ToM task. Greater latency on the PST predicted poorer social function after controlling for symptoms, partially supporting a relationship between ToM and social function in BD.

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).

Recovery and serious mental illness: a review of current clinical and research paradigms and future directions.

INTRODUCTION: Recovery from serious mental illness has historically not been considered a likely or even possible outcome. However, a range of evidence suggests the courses of SMI are heterogeneous with recovery being the most likely outcome. One barrier to studying recovery in SMI is that recovery has been operationalized in divergent and seemingly incompatible ways: as an objective outcome versus a subjective process. Areas covered: This paper offers a review of recovery as a subjective process and recovery as an objective outcome; contrasts methodologies utilized by each approach to assess recovery; reports rates and correlates of recovery; and explores the relationship between objective and subjective forms of recovery. Expert commentary: There are two commonalities of approaching recovery as a subjective process and an objective outcome: (i) the need to make meaning out of one's experiences to engage in either type of recovery and (ii) there exist many threats to engaging in meaning making that may impact the likelihood of moving toward recovery. We offer four clinical implications that stem from these two commonalities within a divided approach to the concept of recovery from SMI.