Psychotherapy to emphasize self-directed recovery for persons with serious mental illness: Contributions from metacognitive reflection and insight therapy (MERIT).

Recovery from serious mental illness (SMI) is a complex process that can be supported by different levels of mental health care, for example, individual psychotherapy. Current individual evidence-based psychotherapy for persons with SMI is often focused on specific objective recovery outcomes, including symptom reduction and functional improvement, and requires a minimum level of insight. Less common but also important are broader, more flexible approaches that allow clients to explore their needs and challenges, without predetermined goals or a certain level of insight. The current article aims to describe (1) the development of metacognitive reflection and insight therapy (MERIT), an evidence-based psychotherapy that is focused on self-determination, or self-directed recovery, and (2) how MERIT advances care for persons with SMI by addressing a significant gap in the field for the treatment of people with SMI with limited metacognitive capacity and insight, offering an adaptable approach emphasizing self-directed recovery. MERIT utilizes a metacognitive framework that is guided by flexible key elements and an interpersonal environment. Training MERIT therapists early in their careers may be helpful in providing a holistic view of SMI to promote self-directed recovery in ways that are personalized and meaningful for each person. MERIT training has been completed in multiple countries across different levels of training (e.g., internship and psychology practicum). Professionals such as psychologists and social workers have effectively played a role in MERIT development and dissemination, which ultimately strives to advance psychotherapy for a wide range of individuals with SMI. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Relationships between Sleep Quality, Introspective Accuracy, and Confidence Differ among People with Schizophrenia, Schizoaffective Disorder, and Bipolar Disorder with Psychotic Features.

People with schizophrenia-spectrum and bipolar disorders have difficulty accurately estimating their abilities and skills (impaired introspective accuracy [IA]) and tend to over- or underestimate their performance. This discrepancy between self-reported and objective task performance has been identified as a significant predictor of functional impairment. Yet, the factors driving this discrepancy are currently unclear. To date, the relationships between sleep quality and IA have not been examined. The current study aimed to explore the relationships between sleep quality and IA in participants diagnosed with schizophrenia (SCZ; n = 36), schizoaffective disorder (SCZ-A; n = 55), and bipolar disorder with psychotic features (BP; n = 87). Participants completed tasks of emotion recognition, estimated their performance on the tasks (used to calculate IA), and provided confidence ratings for their accuracy judgments. Participants also self-reported their sleep quality. These results suggest significantly greater discrepancies between self-reported and actual task scores for those with SCZ and SCZ-A compared to participants with BP. For those with SCZ, lower confidence on the tasks and underestimation of abilities were associated with lower sleep quality, while for those with SCZ-A, lower sleep quality was associated with higher confidence and overestimation of performance. Results suggest differential relationships between diagnostic groups. Future research is needed to further explore the factors driving these differing relationships, particularly the contrasting relationships between SCZ and SCZ-A.

Empathy and Schizotypy: A Network Comparison of the Interpersonal Reactivity Index in High and Low Schizotypy Groups.

Empathy is a multifaceted concept that is vital to effective social functioning; yet, it is impaired in high schizotypy groups. Furthermore, empathy has been found to be a mediator in the relationship between schizotypy and social functioning, highlighting the importance of empathy as a driver in social outcomes. Despite this, the four-factor structure of a widely-used measure of empathy-the Interpersonal Reactivity Index (IRI)-has been found to be psychometrically weak in high schizotypy samples. As such, this study aimed to assess differences in the item-level network of the IRI between high (n = 427) and low schizotypy groups (n = 470). The results reveal that there are significant differences in the structure of these networks, though they evidence similar strengths. Within the high schizotypy group, the network structure was consistent with the four-factor structure of the IRI subscales; items from each subscale clustered together and were distinct from those in the other subscales. By contrast, the low schizotypy group evidenced six clusters that did not mirror the IRI subscales. These results suggest that the item-level structure of the IRI is dependent upon the level of schizotypy of the sample, with the high schizotypy group's network functioning similarly to what would be expected from the original four-factor structure.

Recommendations for the assessment of sexual and gender minority status in serious mental illness research and clinical care.

Sexual and gender minority (SGM) groups experience exposure to minority stress, including discrimination, prejudice, microaggressions, and internalized stigma. Despite the sizable portion of the United States' population that identifies as SGM, relatively little research has been done to comprehensively understand the mental health consequences of SGM stress-particularly as they relate to serious mental illnesses (SMIs)-and SGM status is rarely reported in published studies. This article provides an overview of SGM research among people with SMIs as well as other relevant disorders. Findings show that sizable gaps remain in our knowledge of whether SGM groups experience higher rates or greater severity of SMIs, including schizophrenia-spectrum and bipolar disorders, though findings related to depressive and trauma-related disorders may be able to inform research and treatment for those with SMIs. To increase our understanding of potential mental health disparities for those with SMIs, researchers are encouraged to include measures to assess SGM identity, report upon this demographic information within their manuscripts, and examine differences in rates and severity of SMIs between these groups. Clinicians are encouraged to incorporate demographic questions into their standard intake batteries and initiate discussion of SGM status and minority stressors early on in treatment to promote more positive outcomes for this group. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Schizotypy Moderates the Relationship Between Sleep Quality and Social Cognition.

ABSTRACT: Poor sleep quality has been tied to worse social cognition. Social cognitive deficits have been noted in those with high schizotypy. Yet, no study has assessed whether schizotypy moderates the relationship between sleep quality and social cognition, which may be vital to our understanding of contributors to social functioning. We conducted a cross-sectional analysis of associations of sleep quality and social cognition, with potential moderation by schizotypy. Participants ( n = 906) completed self-report measures of schizotypy, sleep quality, and social cognition. Levels of schizotypy significantly moderated some of the relationships between sleep and social cognition. For participants low in total or interpersonal schizotypy, worse sleep quality was associated with worse theory of mind scores. For participants low in total, disorganized, or cognitive perceptual schizotypy, worse sleep quality was associated with worse self-reported cognitive empathy. For those high in these facets of schizotypy, worse sleep quality was associated with better self-reported cognitive empathy. These results suggest that the individual facets of schizotypy provide additional information and, therefore, are important to assess when examining social cognition and sleep.

Investigating the relationship between specific negative symptoms and metacognitive functioning in psychosis: A systematic review.

BACKGROUND: Disrupted metacognition is implicated in development and maintenance of negative symptoms, but more fine-grained analyses would inform precise treatment targeting for individual negative symptoms. AIMS: This systematic review identifies and examines datasets that test whether specific metacognitive capacities distinctly influence negative symptoms. MATERIALS & METHODS: PsycINFO, EMBASE, Medline and Cochrane Library databases plus hand searching of relevant articles, journals and grey literature identified quantitative research investigating negative symptoms and metacognition in adults aged 16+ with psychosis. Authors of included articles were contacted to identify unique datasets and missing information. Data were extracted for a risk of bias assessment using the Quality in Prognostic Studies tool. RESULTS: 85 published reports met criteria and are estimated to reflect 32 distinct datasets and 1623 unique participants. The data indicated uncertainty about the relationship between summed scores of negative symptoms and domains of metacognition, with significant findings indicating correlation coefficients from 0.88 to -0.23. Only eight studies investigated the relationship between metacognition and individual negative symptoms, with mixed findings. Studies were mostly moderate-to-low risk of bias. DISCUSSION: The relationship between negative symptoms and metacognition is rarely the focus of studies reviewed here, and negative symptom scores are often summed. This approach may obscure relationships between metacognitive domains and individual negative symptoms which may be important for understanding how negative symptoms are developed and maintained. CONLCLUSION: Methodological challenges around overlapping participants, variation in aggregation of negative symptom items and types of analyses used, make a strong case for use of Individual Participant Data Meta-Analysis to further elucidate these relationships.

Investigating the relationship between negative symptoms and metacognitive functioning in psychosis: An individual participant data meta-analysis.

PURPOSE: Negative symptoms are a persistent, yet under-explored problem in psychosis. Disturbances in metacognition are a potential causal factor in negative symptom development and maintenance. This meta-analysis uses individual participant data (IPD) from existing research to assess the relationship between negative symptoms and metacognition treated as summed scores and domains. METHODS: Data sets containing individuals with negative symptoms and metacognition data, aged 16+ with psychosis, were identified according to pre-specific parameters. IPD integrity and completeness were checked and data were synthesized in two-stage meta-analyses of each negative symptoms cluster compared with metacognition in seemingly unrelated regression using restricted maximum likelihood estimation. Planned and exploratory sensitivity analyses were also conducted. RESULTS: Thirty-three eligible data sets were identified with 21 with sufficient similarity and availability to be included in meta-analyses, corresponding to 1301 participants. The strongest relationships observed were between summed scores of negative symptoms and metacognition. Metacognitive domains of self-reflectivity and understanding others' minds, and expressive negative symptoms emerged as significant in some meta-analyses. The uncertainty of several effect estimates increased significantly when controlling for covariates. CONCLUSIONS: This robust meta-analysis highlights the impact of using summed versus domain-specific scores of metacognition and negative symptoms, and relationships are not as clear-cut as once believed. Findings support arguments for further differentiation of negative symptom profiles and continued granular exploration of the relationship between metacognition and negative symptoms.

Sleep disorders in veterans with serious mental illnesses: prevalence in Veterans Affairs health record data.

STUDY OBJECTIVES: This study aimed to estimate the 12-month prevalence of diagnosed sleep disorders among veterans with and without serious mental illnesses (SMI) in Veterans Affairs health record data in 2019. We also examined diagnosed sleep disorders across a 9-year period and explored associations with demographic and health factors. METHODS: This study used health record data from VISN 4 of the Veterans Health Administration from 2011 to 2019. SMI diagnoses included schizophrenia and bipolar spectrum diagnoses as well as major depression with psychosis. Sleep diagnoses included insomnias, hypersomnias, sleep-related breathing disorders, circadian rhythm sleep-wake disorders, and sleep-related movement disorders. Demographic and health-related factors were also collected from the record. RESULTS: In 2019, 21.8% of veterans with SMI were diagnosed with a sleep disorder. This is a significantly higher proportion than for veterans without SMI, 15.1% of whom were diagnosed with a sleep disorder. Sleep disorder rates were highest in veterans with a chart diagnosis of major depression with psychosis. From 2011 to 2019, the overall prevalence of sleep disorders in veterans with SMI more than doubled (10.2%-21.8%), suggesting improvements in the detection and diagnosis of sleep concerns for this group. CONCLUSIONS: Our findings suggest that identification and diagnosis of sleep disorders for veterans with SMI has improved over the past decade, though diagnoses still likely underrepresent actual prevalence of clinically relevant sleep concerns. Sleep concerns may be at particularly high risk of going untreated in veterans with schizophrenia-spectrum disorders. CITATION: Bonfils KA, Longenecker JM, Soreca I, et al. Sleep disorders in veterans with serious mental illnesses: prevalence in Veterans Affairs health record data. J Clin Sleep Med. 2023;19(9):1651-1660.

The paradoxical moderating effects of metacognition in the relationships between self-esteem, depressive symptoms, and quality of life in anorexia and bulimia.

BACKGROUND: Self-esteem and depressive symptoms contribute to a lower quality of life in people suffering from eating disorders. However, limited research has examined whether other factors may affect how these variables influence one another over time. Metacognition is a previously unexplored determinant that may impact the relationships between self-esteem, depressive symptoms, and quality of life in instances of eating disorders. AIM: This study sought to examine metacognitive self-reflectivity and mastery as moderators of the relationships between self-esteem, depressive symptoms, and quality of life and to determine if these relationships are different in people with anorexia compared with people with bulimia. METHODS: Participants with anorexia (n=40) and bulimia (n=40) were recruited from outpatient clinics. The participants were assessed on their metacognitive ability and self-reported on measures to assess their depressive symptoms, self-esteem, and quality of life. RESULTS: The results indicate that metacognitive self-reflectivity moderates the relationship between self-esteem, depressive symptoms, and quality of life in people with anorexia such that when self-reflectivity is high, lower self-esteem and higher depressive symptoms are associated with a lower quality of life. These relationships did not appear to be significant when self-reflectivity was low. In contrast, in the anorexia and bulimia groups, metacognitive mastery appeared to moderate the relationships between self-esteem, depressive symptoms, and quality of life such that when mastery was low, lower self-esteem and higher depressive symptoms were associated with a lower quality of life. These relationships did not appear significant when mastery was high. CONCLUSION: Metacognitive self-reflectivity and mastery seem to play paradoxical moderating roles in the relationships between self-esteem, depressive symptoms, and quality of life in people with anorexia and bulimia. These findings pave the way toward further research and have important clinical implications.

Activism in the Digital Age: The Link Between Social Media Engagement With Black Lives Matter-Relevant Content and Mental Health.

Introduction: Research shows that participation in political activism on social media is linked to psychological stress. Additionally, race-based stress disproportionately affects minorities and is linked to greater psychological symptoms. Yet, the impact of the social media presence of Black Lives Matter (BLM) on mental health has yet to be meaningfully assessed.Methods: This study assessed whether engagement with BLM-related social media vignettes was related to mental health symptoms in two non-clinical samples (total N = 389), using a mixed-methods design. Participants completed an online survey with social media vignettes, self-report inventories of mental health symptoms, and open-ended questions about experiences with and the impact of BLM.Results: Correlations revealed that greater engagement with BLM-related social media posts was related to more severe mental health symptoms. Further, moderation analyses revealed that race significantly moderated the relationship between engagement and anxiety and trauma-related symptoms, such that these relationships were stronger for participants who identified as racial minorities. Qualitative analyses revealed that most participants who were engaged in mental health treatment had not discussed BLM-related topics with their providers, despite many participants reporting disrupted relationships and negative emotions due to exposure to BLM-related social media content.Discussion: Taken together, results suggest that engagement with BLM-related content online is linked to increased mental health symptoms, but these issues are infrequently addressed in treatment. Future research should extend these findings with clinical samples, assess the comfort of therapists in addressing these topics in therapy, and develop interventions to improve mental health in digital activists.

Meaning-making processes across the lifespan: An investigation of the developmental course of metacognitive capacity.

Deficits in metacognitive capacity (i.e., the ability to integrate knowledge of oneself and others into a cohesive whole) have been shown to lead to poor functional outcome in psychosis. However, there is a gap in the literature concerning the role of metacognition in typically developing populations, which makes it difficult to define what level of metacognition is normative and at what point deficits in metacognition suggest pathology. To explore this issue, we utilized cross-sectional design to assess metacognitive capacities among 69 neurotypical adults whose ages varied from 18 to 65 using the Metacognitive Assessment Scale - Abbreviated (MAS-A) and then compared those with MAS-A scores from a second previously gathered sample of 360 adults diagnosed with psychosis across four key developmental windows: emerging adulthood, early adulthood, middle adulthood, and late adulthood. Our findings suggest that in our overall sample, individuals with psychosis had significantly lower levels of metacognitive capacity across all domains assessed by the MAS-A in comparison to neurotypical individuals. Additionally, our data suggest a deleterious effect of psychosis such that individuals with psychosis showed significantly lower metacognition in each developmental stage. Additionally, these differences were largest in emerging and late adulthood and for both groups awareness of others stood out as the single metacognitive domain which was significantly less impaired among older groups. Our results suggest a developmental course for metacognitive capacity such that awareness of others is the sole domain that grows over the lifespan.

Functional outcomes from psychotherapy for people with posttraumatic stress disorder: A meta-analysis.

People with posttraumatic stress disorder (PTSD) experience a wide array of symptoms, often accompanied by significant functional and quality of life impairments. Evidence-based psychotherapies are effective for alleviating symptoms in this group, but functional outcomes following psychotherapy are understudied. This study aimed to synthesize existing work on functional outcomes of psychotherapy to conduct a meta-analytic investigation examining whether people with PTSD experience significant improvements in functioning and quality of life following a course of psychotherapy. A literature search was conducted for studies reporting results of randomized clinical trials of psychotherapies for people diagnosed with PTSD that included a functional or quality of life outcome measured at pre- and post-intervention. Both between-groups and within-groups analyses were conducted using a random effects model. Fifty-six independent samples were included. Results suggest that, on average, people with PTSD experience significant, moderate improvement in functional outcomes after a course of psychotherapy. Taken together, this meta-analysis represents a substantial advance in our understanding of functional outcomes of psychotherapy for people with PTSD. Findings suggest that psychotherapy is one vehicle through which functional outcomes may be improved for this group, though notably to a lesser degree than symptom improvement.

Measuring empathy in groups with high schizotypy: Psychometric evaluation of the Interpersonal Reactivity Index.

Empathy is integral for interpersonal interactions and formation and maintenance of a strong social network. There is wide agreement that empathy is a multidimensional construct, and it is commonly measured with the Interpersonal Reactivity Index (IRI). The IRI is used widely across healthy and clinical populations, yet insufficient evidence exists on whether the IRI is appropriate for use in groups characterized by high levels of schizotypy. This study sought to examine the factor structure and psychometric characteristics of the IRI when used in a sample of participants with high schizotypy. Nine hundred forty-one undergraduates completed the IRI; 218 met criteria for high schizotypy. Confirmatory factor analysis (CFA) was used to test eight a priori factor structures, and scores from the best fitting model were correlated with relevant measures. Of the eight models tested, a two-factor model including the Perspective-Taking and Empathic Concern subscales evidenced the best fit. The original four-factor structure did not meet criteria for adequate fit in our sample. IRI subscale scores correlated with emotional intelligence. Results suggest that a two-factor structure of the IRI is the strongest path forward for use in high schizotypy samples. This approach, in addition to being psychometrically sound, has the added benefit of being a more brief and targeted assessment that aligns well with contemporary models of empathy. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Co-occurring Deficits in Clinical and Cognitive Insight in Prolonged Schizophrenia-Spectrum Disorders: Relationship to Metacognitive Deficits.

People diagnosed with schizophrenia have been broadly observed to experience deficits in clinical and cognitive insight; however, less is understood about how these deficits are related. One possibility is that these deficits co-occur among people when other deficits in cognition are present, such as in executive function, social cognition, and metacognition, which may either promote the development of both forms of poor insight or allow one to negatively influence the other. To explore this possibility, we conducted a cluster analysis using assessments of clinical and cognitive insight among 95 adults with a schizophrenia spectrum disorder. As predicted, this analysis yielded a group with concurrently poor clinical and cognitive insight (n = 36). Additional groups were found with concurrently good clinical and cognitive insight (n = 28) and poor clinical insight and good cognitive insight (n = 31). Groups were then compared on assessments of executive function, social cognition, and metacognition. The group with concurrently lower levels of cognitive and clinical insight had significantly poorer metacognition relative to the other groups. In particular, they tended to form more fragmented and less integrated ideas about themselves and others. No differences were found for executive function or social cognition. The result may suggest that while clinical and cognitive insight is partially orthogonal phenomena, relatively lower levels of metacognition, or difficulties forming integrated ideas about oneself and others, maybe a condition leading to the confluence of lower clinical and cognitive insight. Interventions targeting metacognition may be of particular use for this group.

Application of Interpersonal and Social Rhythm Therapy (IPSRT) for Depression Associated With Schizophrenia Spectrum Disorders.

People with schizophrenia spectrum disorders frequently experience depression, yet depressive symptoms are often unaddressed. The authors propose that interpersonal and social rhythm therapy (IPSRT) may be effective for individuals with these disorders who experience depression. IPSRT is a manualized, evidence-based treatment for bipolar disorders. It combines the core elements of interpersonal psychotherapy for unipolar depression with social rhythm therapy to target disrupted social rhythms. The authors highlight evidence for the potential utility of IPSRT to treat patients with schizophrenia spectrum disorders and present a case example. IPSRT is one promising therapy that could fill a treatment gap for people with schizophrenia spectrum disorders by addressing depressive symptoms. Future work should build on this rationale and case example to design and implement a randomized controlled trial of IPSRT for treatment of schizophrenia spectrum disorders and evaluate needed modifications.

Preliminary examination of a measure of metacognitive perspective-taking: The Interpersonal Block Assembly Task.

OBJECTIVE: People with schizophrenia experience deficits in perspective-taking and metacognition, both of which are related to social impairment in the disorder. Current measurement paradigms vary in their ability to capture the nuanced interconnection of metacognitive and perspective-taking processes during dyadic interactions. This study aimed to introduce the Interpersonal Block Assembly Task (IBAT) as a measure of metacognitive perspective-taking and to provide preliminary evidence of reliability and validity in a sample of people with schizophrenia. METHOD: Thirty-nine people with schizophrenia and 35 healthy people (without a psychiatric diagnosis) participated in this study. Participants were administered the IBAT as well as other measures of social cognition, neurocognition, and symptoms. Indices of internal consistency and interrater reliability were calculated, and convergent validity was assessed using correlational analyses. Analysis of covariance was used to test whether the IBAT could differentiate participant groups. RESULTS: The IBAT total score displayed adequate internal consistency and interrater reliability, and evidenced expected associations with social cognition, neurocognition, and negative symptoms. The IBAT also differentiated patient groups such that those with schizophrenia performed significantly worse. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: This pilot study suggests potential utility of the IBAT and provides preliminary evidence of reliability and validity of this unique measure of metacognitive perspective-taking for people with schizophrenia. With further research, the IBAT may be a valuable contribution to the field of psychiatric rehabilitation, especially considering increased emphasis on social-cognitive and metacognitive intervention approaches. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Levels of distress tolerance in schizophrenia appear equivalent to those found in borderline personality disorder.

OBJECTIVE: Distress tolerance is an important but understudied construct for those with schizophrenia-spectrum disorders. This study compared levels of distress tolerance between people diagnosed with schizophrenia and borderline personality disorder (BPD) to better characterize distress tolerance in schizophrenia-spectrum disorders. METHOD: Using cross-sectional data, we examined group differences in distress tolerance in people with schizophrenia-spectrum disorders (n = 55) and BPD (n = 32) through mean comparison and equivalence analyses. RESULTS: Our results indicate that, in our data, distress tolerance did not differ between those with schizophrenia and those with BPD, and was in fact statistically equivalent between groups. In contrast, those with BPD tended to report more difficulty on some aspects of emotion regulation. CONCLUSION: Findings from this study suggest that increased focus on distress tolerance is called for in research on schizophrenia. Furthermore, people with schizophrenia-spectrum disorders may benefit from interventions targeting distress tolerance.

Emotion-specific performance across empathy tasks in schizophrenia: Influence of metacognitive capacity.

People with schizophrenia exhibit deficits in emotion recognition that are associated with community and social functioning. Emotion-specific performance within emotion recognition tasks has been investigated, suggesting differential patterns of recognition for positive and negative emotions. However, no study has yet examined emotion-specific performance for a higher-order social cognitive construct such as empathy. This study aimed to: 1) examine emotion-specific performance on an empathy task, and 2) elucidate associations with four metacognitive domains: self-reflectivity, understanding of others' minds, decentration, and mastery. Fifty-seven people with schizophrenia or schizoaffective disorder participated. All were administered a computerized, performance-based measure of empathy and an interview-based measure of metacognitive capacity. Results revealed that, consistent with research on facial affect recognition, participants performed significantly better when recognizing happiness in empathic stimuli than all other emotions. Results also revealed positive associations between empathic performance and metacognitive self-reflectivity, across types of emotions. Other metacognitive domains were also associated with performance, but in a less consistent manner. Together, results indicate that not all emotions are created equal - happiness is easier to recognize for those with schizophrenia, suggesting that social cognitive interventions may be more helpful if focused on recognizing negative emotions. Results also emphasize the importance of metacognitive capacity for basic and higher-order social cognitive skills.

Metacognition moderates the relationship between self-reported and clinician-rated motivation in schizophrenia.

INTRODUCTION: Prior work has found varied relationships between self-reported and clinician-rated motivation measures in schizophrenia, suggesting that moderators might impact the strength of this relationship. This current study sought to identify whether metacognition - the ability to form complex representations about oneself, others, and the world - moderates the relationship between self-reported and clinician-rated motivation measures. We also explored whether clinical insight and neurocognition moderated this relationship. METHODS: Fifty-six participants with a schizophrenia-spectrum disorder completed the Motivation and Pleasure Self-Report Scale and the clinician-rated motivation index from the Heinrichs-Carpenter Quality of Life Scale. RESULTS: Metacognition significantly moderated the relationship; self-reported and clinician-rated motivation were positively and significantly correlated only when metacognition was relatively high. Neither clinical insight nor neurocognition moderated the relationship. DISCUSSION: Metacognition appears to be a key variable impacting the strength of the relationship between self-reported and clinician-rated motivation measures and may help to partly explain the varied relationships observed in prior work. Using a metacognitive framework to guide assessment interviews and targeting metacognition in psychosocial treatments may help to improve the synchrony between self-perceptions and clinician ratings of motivation.