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.

Narrative Forewarnings: A Qualitative Analysis of the Themes Preceding Disorganized Speech in Schizophrenia.

Disorganized speech is a critical barrier to recovery in schizophrenia, with profound negative impacts on one's ability to engage with the world. Despite the limited efficacy of existing treatments in addressing disorganization, a qualitative analysis of what leads to disorganization in patient narratives has been lacking. This study addresses this gap through inductive thematic analysis of 30 narrative interviews with individuals with schizophrenia, matched based on whether Formal Thought Disorder (FTD) is present. Through this analysis, we identified four core themes (alienation, interpersonal tension, personal benchmarks, and adverse experiences) and eight subthemes. Our findings suggest that disorganization may serve as a protective mechanism against psychological distress and highlight how the severity of FTD influences these themes. Alienation, particularly due to illness-related stigma, emerged more prominently in those with FTD. The themes of personal benchmarks and interpersonal tension pointed towards a heightened sensitivity to social interactions and self-perception among those with schizophrenia. Adverse experiences, encompassing past challenges, suggest a potential link between trauma and symptom exacerbation. Our qualitative analysis of what themes precede disorganized speech has implications for tailoring psychotherapy. By considering an individual's specific triggers and level of disorganization, therapy may be more effectively targeted to improve recovery-based outcomes. By identifying themes within patient narratives, this study advances our understanding of the qualitative aspects preceding disorganized speech in schizophrenia, paving the way for more personalized and effective recovery-focused interventions.

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).

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).

A Comparison of Personal Recovery in Adults with Early Psychosis and Prolonged Schizophrenia.

BACKGROUND: We aimed to investigate whether personal recovery levels differ between those in early vs prolonged phases of psychosis and if there are different associations with objective outcomes of recovery (i.e., symptom severity and level of functioning). METHOD: Participants included 131 patients with early psychosis and 83 patients with prolonged psychosis. The Recovery Assessment Scale was used to assess personal recovery in both samples. The MIRECC-GAF and the CGI-S were used as measures of objective recovery in the early psychosis group. The PANSS and QoL scales were used as measures of objective recovery in the prolonged psychosis group. RESULTS: People with early psychosis reported better personal recovery scores in all domains, except willingness to ask for help, compared to individuals with prolonged psychosis. Markers of objective recovery were not correlated with personal recovery in the early psychosis sample but were significantly correlated in the prolonged sample. Depressive symptoms were negatively correlated with personal recovery in the prolonged psychosis group. CONCLUSIONS: The relationship between personal and objective recovery may change over time and be dependent on the phase of an individual's illness. In addition, as individuals experience dysfunction over time, they may be more likely to become demoralized and experience lesser degrees of personal recovery.

A Comparison of Personal Recovery in Adults With Early Psychosisand Prolonged Schizophrenia / Comparación de la Recuperación Personal de Adultos con PsicosisTemprana y Prolongada

Background: We aimed to investigate whether personal recovery levelsdiffer between those in early vs prolonged phases of psychosis and ifthere are different associations with objective outcomes of recovery(i.e., symptom severity and level of functioning). Method: Participantsincluded 131 patients with early psychosis and 83 patients with prolongedpsychosis. The Recovery Assessment Scale was used to assess personalrecovery in both samples. The MIRECC-GAF and the CGI-S were usedas measures of objective recovery in the early psychosis group. ThePANSS and QoL scales were used as measures of objective recovery in theprolonged psychosis group. Results: People with early psychosis reportedbetter personal recovery scores in all domains, except willingness to askfor help, compared to individuals with prolonged psychosis. Markers ofobjective recovery were not correlated with personal recovery in the earlypsychosis sample but were significantly correlated in the prolonged sample.Depressive symptoms were negatively correlated with personal recoveryin the prolonged psychosis group. Conclusions: The relationship betweenpersonal and objective recovery may change over time and be dependent onthe phase of an individual’s illness. In addition, as individuals experiencedysfunction over time, they may be more likely to become demoralized andexperience lesser degrees of personal recovery.

Antecedentes: nuestro objetivo fue investigarsi los niveles de recuperación personal difieren entre pacientes que seencuentran en la fase temprana y prolongada de la psicosis y si existendiferentes asociaciones con medidas de recuperación objetiva. Método:131 pacientes con psicosis temprana y 83 pacientes con psicosisprolongada. La escala RAS fue utilizada para evaluar la recuperaciónpersonal en ambas muestras. El MIRECC-GAF y el CGI-S fueron las medidas de recuperación objetiva en el grupo de psicosis temprana. La sescalas PANSS y QoL fueron las medidas de recuperación objetiva enel grupo de psicosis prolongada. Resultados: las personas con psicosistemprana informaron mejores puntuaciones de recuperación personal entodos los dominios, excepto en la disposición a pedir ayuda, comparados elgrupo de psicosis prolongada. Los marcadores de recuperación objetiva nose correlacionaron con la recuperación personal en la muestra de psicosistemprana. Los síntomas depresivos se correlacionaron negativamente conla recuperación personal en el grupo de psicosis prolongada. Conclusiones: la relación entre recuperación personal y objetiva puede cambiar con eltiempo y depender de la fase del trastorno psicótico. A medida que laspersonas experimentan disfunción con el tiempo es más probable que sedesmoralicen y experimenten un menor grado de recuperación personal.

Childhood Maltreatment and Psychosis: A Comparative Validity Study of Maltreatment Indices.

Childhood maltreatment is a robust risk factor for psychosis, but it remains unclear whether different measurement methods provide equivalent validity in predicting psychotic symptoms. This study compared the predictive validity of two common indices of maltreatment at age 12-children's self-report and Child Protective Services (CPS) reports-on the development of psychotic symptoms at age 18 using data from a large, multisite longitudinal study (N = 629). Consistent with prior research, agreement was low between indices, with the prevalence of self-reported maltreatment being 2-3 times higher. A quarter of the sample endorsed at least one psychotic symptom at age 18, most commonly delusions. While CPS-indicated maltreatment was generally not associated with later psychotic symptoms, all forms of self-reported maltreatment were. Sexual abuse demonstrated a particularly strong relationship with psychosis, especially hallucinations. These results suggest that self-reports may provide stronger predictive validity than CPS indications of maltreatment in the assessment of psychosis risk, indicating that a child's interpretation of trauma matters more than the traumatic event itself in this regard.

Meaning, integration, and the self in serious mental illness: Implications of research in metacognition for psychiatric rehabilitation.

OBJECTIVE: It has been established that recovery is a common outcome for adults diagnosed with serious mental illness which involves objective and subjective phenomenon. While considerable work has examined objective aspects of recovery, it remains difficult to know how to quantify the processes which support more subjective aspects of recovery related to sense of self. This article explores the potential of recent research on metacognition to offer new avenues to measure the processes which make a sense of self available within the flow of life. METHOD: Emerging definitions of metacognition using an integrative model of metacognition are reviewed. Research is presented suggesting adults diagnosed with serious mental illness are often confronted by metacognitive deficits which interfere with their ability to make sense of their psychiatric challenges and effectively direct their own recovery. FINDINGS: Metacognitive capacity may be a quantifiable phenomenon which contributes to certain aspects of recovery related to meaning making, agency and self-direction. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Promoting metacognitive capacity may be a previously unrecognized active element of existing rehabilitative interventions. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

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).

Relationship of Metacognition and Insight to Neural Synchronization and Cognitive Function in Early Phase Psychosis.

Metacognition is the process of thinking about one's own mental states. It involves a range of faculties that allow an individual to integrate information and form understanding of self and others, and use this understanding to respond to life challenges. Clinical insight is the awareness of one's mental illness, its consequences, and the need for treatment. Persons with psychotic disorders show impaired metacognition and insight, but the neurobiological bases for these impairments are not well characterized. We hypothesized that metacognition and insight may depend on capacity of neural circuits to synchronize at gamma frequencies, as well as the integrity of underlying cognitive processes. In order to test these hypotheses, 17 adults with early phase psychosis were evaluated. Metacognition was assessed with the Metacognition Assessment Scale-Abbreviated, and insight was assessed with the Scale of Unawareness of Illness-Abbreviated. The auditory steady state response (ASSR) to gamma range stimulation (40 Hz) was used as an index of neural synchronization. Cognitive function was assessed using the Brief Assessment of Cognition in Schizophrenia. Increases in ASSR power were associated with poorer metacognition and insight. Higher cognitive performance was associated with higher levels of metacognitive function and insight. These findings suggest that altered neural synchronization and constituent cognitive processes affect both metacognition and insight in early phase psychosis and may offer targets for both pharmacological and psychotherapeutic interventions.

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.

Recovery in First-Episode Psychosis: A Case Study of Metacognitive Reflection and Insight Therapy (MERIT).

Despite historically pessimistic views from both the professional community and lay public, research is emerging that recovery from psychosis is possible. Recovery has evolved to include not only a reduction in symptoms and return to functioning, but a sense of agency and connection to meaningful roles in life. The development of a more comprehensive conceptualization of recovery has particular importance in the treatment of first-episode psychosis, because early intervention may avoid some of the prolonged dysfunction that may make recovery difficult. As the mental health field moves to intervene early in the course of psychosis and to support recovery for individuals with severe mental illness, it is essential to develop and assess interventions that may promote a more comprehensive recovery. This case illustration offers an account of a type of integrative psychotherapy that may assist individuals in achieving recovery: metacognitive reflection and insight therapy (MERIT).

Metacognitive Reflection and Insight Therapy for Schizophrenia: Case Study of a Patient With a Co-Occurring Substance Use Disorder.

Decrements in metacognitive functioning, or the ability to form complex and integrated representations of oneself and others, have been identified as a core feature of schizophrenia. These deficits have been observed to be largely independent of the severity of psychopathology and neurocognitive functioning and are linked to poor outcomes for those with the disorder. This study is a case illustration of the efficacy of metacognitive reflection and insight therapy (MERIT) in increasing the metacognitive capacity of an individual diagnosed as having co-occurring schizophrenia and a substance use disorder during three years of individual therapy. The eight elements of MERIT, which promote metacognitive growth, are presented as they apply to the present case. Case conceptualization, outcomes, and prognosis are also presented. These eight elements enabled the patient to move from a state of gross disorganization-unable to identify his thoughts or present them in a linear fashion-to one in which he was able to develop increasingly complex ideas about himself and others and integrate this understanding into a richer sense of himself, of his psychological challenges, and of the role that substance use played in his life. Results of the study also illustrate the foundational necessity of self-reflectivity in order to facilitate understanding of the mind of others and the relationship between psychological pain and the emergence of disorganization.

Self-stigma in PTSD: Prevalence and correlates.

Self-stigma is the internalization of negative societal stereotypes about those with mental illnesses. While self-stigma has been carefully characterized in severe mental disorders, like schizophrenia, the field has yet to examine the prevalence and correlates of self-stigma in post-traumatic stress disorder (PTSD). Thus, we assessed self-stigma in veterans diagnosed with PTSD and compared with veterans with schizophrenia. We further examined associations between PTSD, depressive symptoms and self-stigma in the PTSD sample. Data came from two larger studies of people with PTSD (n = 46) and schizophrenia-spectrum disorders (n = 82). All participants completed the Internalized Stigma of Mental Illness Scale (ISMIS). Results revealed that people with schizophrenia report more experiences of discrimination as a result of stigma than do those with PTSD, but these diagnostic groups did not differ for other subscales. In the PTSD group, feelings of alienation positively correlated with PTSD and depressive symptoms; other subscales positively correlated with depressive symptoms only. Taken together, results suggest a significant level of self-stigma exists among veterans with PTSD, and that self-stigma has an effect on PTSD and commonly comorbid symptoms, like depression. Future work should investigate whether current self-stigma interventions for other groups could be applicable for those with PTSD.

Metacognitive self-reflectivity moderates the relationship between distress tolerance and empathy in schizophrenia.

Deficits in empathy seen in schizophrenia are thought to play a major role in the social dysfunction seen in the disorder. However, little work has investigated potential determinants of empathic deficits. This study aimed to fill that gap by examining the effects of two variables on empathy - distress tolerance and metacognitive self-reflectivity. Fifty-four people with schizophrenia-spectrum disorders receiving services at an urban VA or community mental health center were assessed for empathy, metacognition, and distress tolerance. Bivariate correlations and moderation methods were used to ascertain associations amongst these variables and examine interactions. Results revealed that, against hypotheses, empathy was not related at the bivariate level to either distress tolerance or metacognitive self-reflectivity. However, consistent with hypotheses, moderation analyses revealed that participants with higher self-reflectivity showed no relationship between distress tolerance and empathy, while those with lower self-reflectivity showed a relationship such that reduced ability to tolerate distress predicted reduced empathy. Taken together, results of this study suggest that lack of distress tolerance can negatively affect empathy in people with schizophrenia with lesser capacity for metacognitive self-reflection; thus, fostering self-reflectivity may help overcome that negative impact. Future work is needed investigating the impact of metacognitively-tailored interventions on empathy in this population.

The experience and expression of anger in posttraumatic stress disorder: the relationship with metacognition.

BACKGROUND: Anger experience and expression are a common issue in those experiencing PTSD. However, it remains unclear what variables affect anger and its expression in PTSD. AIMS: To explore the relationships of synthetic forms of metacognition and metacognitive beliefs with anger experience and expression in PTSD, independent of the effects hyperarousal and depression symptoms. METHOD: Participants were 51 veterans with diagnosed with PTSD. Metacognition was assessed using the Metacognition Assessment Scale-Abbreviated (MAS-A) and the Metacognitions Questionnaire (MCQ). Depression, PTSD symptom severity, and seven domains of anger expression were also assessed. RESULTS: Correlations showed after controlling for overall levels of hyperarousal, higher MAS-A total scores were related to lower levels of State Anger, Feeling Angry, Expressing Anger Physically, and Anger Expression in. Lower MCQ scores were related to lower State anger, Expressing anger verbally, and Expressing anger physically. Higher levels of depression were related to higher levels of Trait anger, Expressing anger physically, Anger expression out, and Anger expression in. Multiple regressions suggested that the MAS-A and MCQ predicted unique portions of the variance in anger experience and expression. CONCLUSIONS: Metacognitive deficits may affect anger experience and expression in those with PTSD and may be an important treatment target.

Promoting recovery from severe mental illness: Implications from research on metacognition and metacognitive reflection and insight therapy.

Research indicates that individuals with schizophrenia recover. Recovery, however means different things to different individuals and regardless of what kind of experiences define recovery, the individual diagnosed with the serious mental illness must feel ownership of their recovery. This raises the issue of how mental health services should systematically promote recovery. This paper explores the practical implications for research on metacognition in schizophrenia for this issue. First, we present the integrated model of metacognition, which defines metacognition as the spectrum of activities which allow individual to have available to themselves an integrated sense of self and others as they appraise and respond to the unique challenges they face. Second, we present research suggesting that many with schizophrenia experience deficits in metacognition and that those deficits compromise individuals' abilities to manage their lives and mental health challenges. Third, we discuss a form of psychotherapy inspired by this research, Metacognitive Reflection and Insight Therapy which assists individuals to recapture the ability to form integrated ideas about themselves and others and so direct their own recovery. The need for recovery oriented interventions to focus on process and on patient's purposes, assess metacognition and consider the intersubjective contexts in which this occurres is discussed.

Insight in schizophrenia spectrum disorders: relationship with behavior, mood and perceived quality of life, underlying causes and emerging treatments.

Poor insight in schizophrenia is prevalent across cultures and phases of illness. In this review, we examine the recent research on the relationship of insight with behavior, mood and perceived quality of life, on its complex roots, and on the effects of existing and emerging treatments. This research indicates that poor insight predicts poorer treatment adherence and therapeutic alliance, higher symptom severity and more impaired community function, while good insight predicts a higher frequency of depression and demoralization, especially when coupled with stigma and social disadvantage. This research also suggests that poor insight may arise in response to biological, experiential, neuropsychological, social-cognitive, metacognitive and socio-political factors. Studies of the effects of existing and developing treatments indicate that they may influence insight. In the context of earlier research and historical models, these findings support an integrative model of poor insight. This model suggests that insight requires the integration of information about changes in internal states, external circumstances, others' perspectives and life trajectory as well as the multifaceted consequences and causes of each of those changes. One implication is that treatments should, beyond providing education, seek to assist persons with schizophrenia to integrate the broad range of complex and potentially deeply painful experiences which are associated with mental illness into their own personally meaningful, coherent and adaptive picture.

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.

Metacognitive Reflection and Insight Therapy for Early Psychosis: A preliminary study of a novel integrative psychotherapy.

Poor insight impedes treatment in early phase psychosis (EPP). This manuscript outlines preliminary findings of an investigation of the novel metacognitively oriented integrative psychotherapy, Metacognitive Reflection and Insight Therapy, for individuals with early phase psychosis (MERIT-EP). Twenty adults with EPP and poor insight were randomized to either six months of MERIT-EP or treatment as usual (TAU). Therapists were trained and therapy was successfully delivered under routine, outpatient conditions. Insight, assessed before and after treatment, revealed significant improvement for the MERIT-EP, but not TAU, group. These results suggest MERIT-EP is feasible to deliver, accepted by patients, and leads to clinically significant improvements in insight.