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

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

Metacognitive Reflection and Insight Therapy for Persons With Severe Negative Symptoms of Schizophrenia.

Individuals with schizophrenia possess enduring deficits that limit their capacity for interpersonal connection. Negative symptoms of schizophrenia provide additional barriers to interpersonal relatedness in that they include a range of deficits related to an individual's ability to express and experience emotions-basic human capacities that are needed for daily functioning and an acceptable quality of life. Additionally, metacognitive deficits are closely related to the development and maintenance of negative symptoms; previous research has indicated that treatment of negative symptoms should focus on providing interventions that target metacognition. To explore this issue, a case study is presented in which ongoing assessments of metacognition were used to guide the selection of interventions. These interventions were selected to match the client's capacity for metacognition at that time and were aimed toward practicing and increasing development of metacognitive capacity. Improvements in function and metacognitive capacity are reported, and implications for research and theory are discussed.

Metacognitive Reflection and Insight Therapy (MERIT): Application to a Long-Term Therapy Case of Borderline Personality Disorder.

Impairments in metacognitive capacity-or the processes that enable individuals to access, understand, and integrate their ideas about their own and others' mental states-are a core barrier to recovery for many people with borderline personality disorder. Although therapeutic approaches that focus on metacognitive capacity are emerging, few deal with the concept of recovery at a foundational level. This article describes how a form of metacognitively oriented psychotherapy focused on recovery, metacognitive reflection and insight therapy (MERIT), assisted a patient with borderline personality disorder and initial metacognitive deficits to develop a complex understanding of himself and others and then to use that knowledge to act as an agent in the world and effectively respond to life challenges. The eight elements of MERIT that stimulate and promote metacognitive capacity are presented with an emphasis on how they were implemented to assist the patient in achieving recovery.

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.

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.

Metacognition Is Necessary for the Emergence of Motivation in People With Schizophrenia Spectrum Disorders: A Necessary Condition Analysis.

Metacognition deficits are a putative cause of reduced motivation in people with schizophrenia spectrum disorders. However, it is unclear whether certain levels of metacognition are necessary for motivation to emerge. This study used a Necessary Condition Analysis to test whether metacognition was necessary for the presence of motivation and to identify the minimum level of metacognition necessary for high motivation to be possible in people with schizophrenia spectrum disorders (N = 175). Participants completed clinician-rated measures of metacognition and motivation. Necessary Condition Analysis revealed that metacognition is a necessary condition for motivation and that high levels of motivation were only possible, although not guaranteed, when at least a basic level of metacognition was present. The findings suggest that metacognition is a necessary building block for the development of motivation. Results suggest that targeting metacognition may be essential for improving motivation among people with schizophrenia spectrum disorders who do not meet this metacognition threshold.

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

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

Metacognition moderates the relationship between dysfunctional self-appraisal and social functioning in prolonged schizophrenia independent of psychopathology.

OBJECTIVES: Both dysfunctional self-appraisal and metacognitive deficits, or impairments in the ability to form complex and integrated ideas about oneself and others, may contribute to social deficits in schizophrenia. Little is known, however, about how they interact with each other. In this study, we examined the hypothesis that both higher metacognition and more positive self-appraisal are necessary for increased social functioning. METHODS: Concurrent assessments of self-appraisal, metacognition, and social functioning were gathered from 66 adults with schizophrenia in a non-acute phase of disorder. Three forms of self-appraisal were used: self-esteem, hope and self-efficacy. Metacognition was assessed using the Metacognitive Assessment Scale-Abbreviated, and social functioning with the Quality of Life Scale. Measures of psychopathology, neurocognition and social cognition were also gathered for use as potential covariates. RESULTS: A single index of self-appraisal was generated from subjecting the assessments of self-appraisal to a principal components analysis. Linear regression analyses revealed that after controlling for severity of psychopathology, metacognition moderated the effect of the self-appraisal factor score upon social functioning. A median split of metacognition and the self-appraisal index yielded four groups. ANCOVA analyses revealed that participants with higher levels of metacognition and more positive self-appraisal had greater capacities for social relatedness than all other participants, regardless of levels of positive and negative symptoms. Correlational analyses revealed that metacognition but not self-appraisal was related to the frequencies of social contact independent of the effects of psychopathology. Assessments of social cognition and neurocognition were not significantly linked with social dysfunction. CONCLUSION: Greater social functioning is made possible by a combination of both more positive self-appraisals and greater metacognitive capacity. Individuals with schizophrenia who struggle to relate to others may benefit from interventions which address both their beliefs about themselves and their capacity for metacognition.

The Role of Metacognitive Self-Reflectivity in Emotional Awareness and Subjective Indices of Recovery in Schizophrenia.

Emotional awareness deficits in people with schizophrenia have been linked to poorer objective outcomes, but no work has investigated the relationship between emotional awareness and subjective recovery indices or metacognitive self-reflectivity. The authors hypothesized that increased emotional awareness would be associated with greater self-esteem, hope, and self-reflectivity and that self-reflectivity would moderate links between emotional awareness and self-esteem and hope-such that significant relationships would only be observed at lower levels of self-reflectivity. Participants were 56 people with schizophrenia spectrum disorders. Correlations revealed that better emotional awareness was significantly associated with increased self-esteem and hope but not self-reflectivity. Self-reflectivity moderated the relationship between emotional awareness and self-esteem but not hope. Overall, findings suggest that emotional awareness may affect self-esteem for those low in self-reflectivity, but other factors may be important for those with greater self-reflectivity. Results emphasize the importance of interventions tailored to enhance self-reflective capacity in clients with schizophrenia.

Intrinsic motivation as a mediator between metacognition deficits and impaired functioning in psychosis.

OBJECTIVE: Poor functioning has long been observed in individuals with psychosis. Recent studies have identified metacognition - one's ability to form complex ideas about oneself and others and to use that information to respond to psychological and social challenges-as being an important determinant of functioning. However, the exact process by which deficits in metacognition lead to impaired functioning remains unclear. This study first examined whether low intrinsic motivation, or the tendency to pursue novel experiences and to engage in self-improvement, mediates the relationship between deficits in metacognition and impaired functioning. We then examined whether intrinsic motivation significantly mediated the relationship when controlling for age, education, symptoms, executive functioning, and social cognition. DESIGN: Mediation models were examined in a cross-sectional data set. METHODS: One hundred and seventy-five individuals with a psychotic disorder completed interview-based measures of metacognition, intrinsic motivation, symptoms, and functioning and performance-based measures of executive functioning and social cognition. RESULTS: Analyses revealed that intrinsic motivation mediated the relationship between metacognition deficits and impaired functioning (95% CI of indirect effect [0.12-0.43]), even after controlling for the aforesaid variables (95% CI of indirect effect [0.04-0.29]). CONCLUSIONS: Results suggest that intrinsic motivation may be a mechanism that underlies the link between deficits in metacognition and impaired functioning and indicate that metacognition and intrinsic motivation may be important treatment targets to improve functioning in individuals with psychosis. PRACTITIONER POINTS: The findings of this study suggest that deficits in metacognition may indirectly lead to impaired functioning through their effect on intrinsic motivation in individuals with psychosis. Psychological treatments that target deficits in both metacognition and intrinsic motivation may help to alleviate impaired functioning in individuals with psychosis. LIMITATIONS: The cross-sectional design of this study is a limitation, and additional longitudinal studies are needed to confirm the direction of the findings and rule out rival hypotheses. Generalization of the findings may be limited by the sample composition. It may be that different relationships exist between metacognition, intrinsic motivation, and functioning in those with early psychosis or among those in an acute phase or who decline treatment.

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

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

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

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

Metacognitive reflective and insight therapy for people in early phase of a schizophrenia spectrum disorder.

Schizophrenia often involves a loss of metacognitive capacity, the ability to form complex and integrated representations of self and others. Independent of symptoms and neurocognition, deficits in synthetic metacognition are related to difficulties of engaging in goal-directed activities in social and vocational settings. Within this backdrop, we provide a case report of the effects of Metacognitive Reflective Insight Therapy (MERIT) that assisted a patient suffering from first episode schizophrenia during 2 years of individual psychotherapy. A total of 8 elements of MERIT that stimulate and promote metacognitive capacity are presented. As illustrated in this report, these procedures helped the patient move from a state in which he had virtually no complex ideas about himself or others to one in which he had developed integrated and realistic ideas about his own identity and the identity of others. He then could use these representations to understand and effectively respond to life challenges.

Deficits in Metacognitive Capacity Are Related to Subjective Distress and Heightened Levels of Hyperarousal Symptoms in Adults With Posttraumatic Stress Disorder.

Among persons with posttraumatic stress disorder (PTSD), the severity of symptoms and concurrent distress are not fully explained by trauma severity. Interest has consequently arisen in the psychological processes that cause distress and heighten PTSD symptoms. This study accordingly sought to examine whether differences in metacognitive capacity are related to levels of emotional distress, avoidance/numbing, and hyperarousal. Participants were 48 adults with a confirmed diagnosis of PTSD. Comparison groups included 51 adults with HIV and 183 with schizophrenia. Metacognition, emotion recognition, depression, and emotional distress and levels of avoidance/numbing and hyperarousal were assessed concurrently using the Metacognition Assessment Scale-Abbreviated, the Bell Lysaker Emotion Recognition Test, the Beck Depression Inventory, and the Clinician-Administered PTSD Scale. Results revealed that the PTSD group had better ratings of overall metacognitive capacity than the schizophrenia group and specifically poorer levels of metacognitive mastery, or the ability to use metacognitive knowledge to respond to challenges, than the HIV group. Within the PTSD group, poorer metacognitive mastery was linked with greater distress and higher hyperarousal when depression was controlled for statistically. Emotion recognition was not linked with distress or symptom severity. Results are consistent with models in which symptom severity in PTSD is related to the extent to which persons can use knowledge of themselves and others to find ways to respond to distress that match their own unique needs.

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

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

Anhedonia in prolonged schizophrenia spectrum patients with relatively lower vs. higher levels of depression disorders: associations with deficits in social cognition and metacognition.

This study has sought to explore whether there are at least two subtypes of anhedonia in schizophrenia: one closely linked with depression and another that occurs in the absence of depression which is related to a general paucity of internal experience. Participants were 163 adults with schizophrenia who completed assessments of depression, anhedonia, executive functioning, positive and negative symptoms, social cognition and metacognition. A cluster analysis based on participants' depression and anhedonia symptom scores produced three groups: High Depression/High Anhedonia (n=52), Low Depression/Low Anhedonia (n=52), and Low Depression/High Anhedonia (n=59). An ANCOVA and post hoc comparisons controlling for positive and negative symptoms found that the Low Depression/High Anhedonia group had poorer metacognition and social cognition than other groups. These findings point to the possibility of a subtype of anhedonia in schizophrenia, one occurring in the relative lesser levels of depression, and tied to deficits in the ability to think about oneself and others.

Overcoming recruitment barriers revealed high readiness to participate and low dropout rate among people with schizophrenia in a randomized controlled trial testing the effect of a Guided Self-Determination intervention.

BACKGROUND: Recruitment is one of the most serious challenges in performing randomized controlled trials. Often clinical trials with participants diagnosed with schizophrenia are terminated prematurely because of recruitment challenges resulting in a considerable waste of resources in the form of time, funding, and the participants' efforts. Dropout rates in schizophrenia trials are also high.Recruitment challenges are often due to patients not wanting to participate in research but can also be due to clinicians' concerns regarding individuals diagnosed with schizophrenia as participants in research. This paper reports how overcoming recruitment challenges not related to patients revealed high readiness to take part and low dropout rates in a one year long randomized controlled trial testing Guided Self-Determination (GSD) among outpatients with schizophrenia receiving treatment in Assertive Outreach Teams in the northern part of Denmark. METHODS: GSD is a shared decision-making and mutual problem-solving method using reflection sheets, which was developed in diabetes care and adjusted for this study and utilized by patients with schizophrenia. Descriptive data on strategies to overcome recruitment challenges were derived from notes and observations made during the randomized controlled trial testing of GSD in six outpatient teams. RESULTS: Three types of recruitment challenges not related to patients were identified and met during the trial: 1) organizational challenges, 2) challenges with finding eligible participants and 3) challenges with having professionals invite patients to participate. These challenges were overcome through: 1) extension of time, 2) expansion of the clinical recruitment area and 3) encouragement of professionals to invite patients to the study. Through overcoming these challenges, we identified a remarkably high patient-readiness to take part (101 of 120 asked accepted) and a low dropout rate (8%). CONCLUSION: Distinction between recruitment challenges was important in discovering the readiness among patients with schizophrenia to take part in and complete a trial with the GSD-intervention.

Stereotype endorsement, metacognitive capacity, and self-esteem as predictors of stigma resistance in persons with schizophrenia.

OBJECTIVE: While research continues to document the impact of internalized stigma among persons with schizophrenia, little is known about the factors which promote stigma resistance or the ability to recognize and reject stigma. This study aimed to replicate previous findings linking stigma resistance with lesser levels of depression and higher levels of self-esteem while also examining the extent to which other factors, including metacognitive capacity and positive and negative symptoms, are linked to the ability to resist stigma. METHOD: Participants were 62 adults with schizophrenia-spectrum disorders who completed self-reports of stigma resistance, internalized stigma, self-esteem, and rater assessments of positive, negative, disorganization, and emotional discomfort symptoms, and metacognitive capacity. RESULTS: Stigma resistance was significantly correlated with lower levels of acceptance of stereotypes of mental illness, negative symptoms, and higher levels of metacognitive capacity, and self-esteem. A stepwise multiple regression revealed that acceptance of stereotypes of mental illness, metacognitive capacity, and self-esteem all uniquely contributed to greater levels of stigma resistance, accounting for 39% of the variance. CONCLUSION: Stigma resistance is related to, but not synonymous with, internalized stigma. Greater metacognitive capacity, better self-esteem, and fewer negative symptoms may be factors which facilitate stigma resistance.

Metacognitive and social cognition deficits in patients with significant psychiatric and medical adversity: a comparison between participants with schizophrenia and a sample of participants who are HIV-positive.

Research exploring metacognition and social cognition in schizophrenia has tended to use control groups experiencing relatively little adversity. Therefore, it remains unclear whether the deficits found among persons with schizophrenia are merely the result of greater life adversity. To explore this issue, we assessed metacognition and social cognition among 40 participants with schizophrenia and 25 adults with HIV. We chose to explore this phenomenon in people with HIV given the literature suggesting that this group experiences significant adversity. Measures of metacognition and social cognition included the Metacognition Assessment Scale (MAS), the Hinting test, and the Bell-Lysaker Emotion Recognition Test (BLERT). After controlling for education, years since diagnosis, and memory, the schizophrenia group performed more poorly on the MAS and the Hinting test. No differences were found on the BLERT. The results are consistent with the possibility that schizophrenia is linked to decrements in metacognition and some forms of social cognition.

Associations of metacognition with symptoms, insight, and neurocognition in clinically stable outpatients with schizophrenia.

Research indicates that many with schizophrenia experience deficits in metacognitive capacity or the ability to form complex representations of themselves and others. Previous work has found that metacognitive capacity in schizophrenia is correlated with symptoms, insight, and neurocognitive deficits. We sought to replicate these results in a sample of Italian participants treated in a community setting. Metacognition was assessed with the abbreviated Metacognition Assessment Scale and correlated with concurrent assessment of symptoms, insight, and neurocognitive abilities, including verbal and visual memory, premorbid intelligence, processing speed, and executive function. Correlations revealed that, consistent with previous work, lesser capacity for self-reflectivity was related to greater levels of negative symptoms, poorer insight, neurocognitive impairment (particularly impairments in verbal and visual memory) premorbid intelligence, and processing speed. Other metacognitive domains were also linked to poorer neurocognition. Results support contentions that deficits in metacognition are linked with negative symptoms, insight, and neurocognitive deficits.