The Mutual Development of Intersubjectivity and Metacognitive Capacity in the Psychotherapy for Persons with Schizophrenia

Conceptualisation and Measurement of Reflective Process in Psychotherapy: A Systematic Scoping Review

Psychological therapies use talk as a means to produce change for individuals who are experiencing distress. Despite a significant body of research comparing approaches, there is little evidence for the superiority of one model over another. The process of reflection has been suggested as a common factor across modalities, and research aiming to measure this phenomenon is emerging. This scoping review is focussed on the conceptualisations, measurement and process outcomes of reflective talk as it occurs during therapy. Twenty-two studies were selected from a total of 3712 papers identified following a systematic search of SCOPUS, MEDLINE, PsychINFO and Web of Science databases. A variety of descriptors emerged: intrapersonal constructs such as mentalization and metacognition tended to view reflectivity as an individually acquired skill or trait, where other descriptors adopted an interpersonal understanding of reflection as co-constructed through dialogue. Our findings suggest a shift from individual to intersubjective understandings of reflecting processes in therapy may be a valuable area for future research.

Finding the Person in the Disorder: Adapting Metacognitive Reflection and Insight Therapy for Bipolar Mood Disorder (MERIT-BD)

Metacognitive Reflection and Insight Therapy (MERIT) was originally developed as an integrative recovery-oriented therapeutic approach to address the needs of people with a diagnosis of schizophrenia and other forms of severe mental illness. The approach, conceptualized as transtheoretical, aims to promote a more coherent and synthetic sense of self, through stimulating insight, sense of coherence, and metacognitive capacity. We argue that MERIT therapy, designed to facilitate peoples’ ability to form complex ideas about themselves and others and to use this knowledge to respond to psychological problems, has application in addressing deficits associated with bipolar disorder (BD), where there may be a significant injury to the person’s sense of self. That is, the therapy addresses the nascent sense of self in a context where disturbance of mood is dominant, and in relation to the experience of episodic manic episodes which may be understood as dissociative events, often associated with shame. The application of the therapeutic approach, which we term MERIT-BD draws upon MERIT’s primary principle of facilitating complexity and integration of the self, and additionally addresses shame, allowing for the facilitation of metacognitive capacity and insight in the context of finding the person. This approach will be illustrated with case vignettes illustrating the application of key components of MERIT-BD. Early findings drawn from a series of case studies are encouraging.

A qualitative evaluation of the effects of Metacognitive Reflection and Insight Therapy: 'Living more consciously'

OBJECTIVES

Extensive research showed that one of the major difficulties that people with schizophrenia spectrum disorders are struggling with involves their ability to reflect on their own and others' mental activities, also defined as metacognition. Several new psychotherapies have been developed to assist patients (re)gain metacognitive capacity, including Metacognitive Reflection and Insight Therapy (MERIT). The current study investigated the client's subjective experience of psychotherapy, to determine whether service users found MERIT effective and whether these gains align with quantitative findings, which processes they considered responsible for these benefits, in which ways participants found MERIT similar or different from other interventions, and whether they experienced non-desirable factors and outcomes.

DESIGN

All participants who had participated in a randomized controlled trial investigating the efficacy of MERIT were offered a structured post-therapy interview by an independent assessor. Fourteen out of 18 (77%) participants, all of whom had completed therapy, responded.

RESULTS

Most participants (10/14) indicated that they had experienced the therapy as beneficial to their recovery, and in general contributed to their understanding of their own thinking, which maps closely onto the quantitative findings reported elsewhere. They mainly attributed these changes to their own active role in therapy, the intervention letting them vent and self-express, and forming an alliance with the therapist.

CONCLUSIONS

Participants reports of change map closely onto the quantitative findings from the randomized controlled trial. Findings are discussed in the frameworks of the metacognitive model of psychosis and the integrative intersubjective model of psychotherapy for psychosis emphasizing the role of the clients as active agent of change.

PRACTITIONER POINTS

The use of a systematic, qualitative interview at the conclusion of therapy may yield important information regarding process and outcome. Analysis of the interview revealed that clients' perceptions regarding change within themselves closely maps onto quantitative findings. MERIT may not be the appropriate intervention for all clients; some may prefer a more solution-oriented approach such as CBTp or Metacognition-Oriented Social Skills training. Self-expressing with a trained clinician may be therapeutic in itself.

Mentalization and Psychosis: A Rationale for the Use of Mentalization Theory to Understand and Treat Non-affective Psychotic Disorder

Social functioning can be severely impaired in non-affective psychotic disorder (NAPD). Current models of psychosis pathogenesis do not tend to focus on social dysfunction and pharmacological treatment fails to ameliorate it. In this article, we propose that mentalization theory provides a valuable contribution to the understanding and treatment of NAPD. Impaired mentalizing may contribute to both positive and negatives symptoms as well as social dysfunction observed in NAPD. Furthermore, impaired mentalizing may help explain the relation between childhood abuse, insecure attachment and psychosis. Mentalization based treatment may contribute to the functional recovery of NAPD patients as it targets the social cognitive processes underlying social interaction. The article includes a description of the principles of MBT in general, specific characteristics of using MBT with patients with NAPD and a clinical vignette to illustrate these principles.

Approaching patients with hyperreflectivity and perplexity: an empirical qualitative investigation

OBJECTIVE

Perplexity and hyperreflectivity are considered important aspects of self-disorders in patients with schizophrenia, yet knowledge of the appropriate psychotherapy for these patients is sparse. We aimed to explore how phenomenological psychologists or psychiatrists described their approach to these patients and their own emotional response when hyperreflectivity and perplexity emerged in therapy or consultations.

METHODS

Four e-mail interviews with experienced clinical researchers within the field of phenomenology and schizophrenia were examined using a double hermeneutic qualitative analysis.

RESULTS

The informants offered reassurance by authority and the encouragement of sharing of experiences interlaced in the beginning of therapy. Later they went on relating expressions of hyperreflectivity and perplexity to emotions, life events and goals. They described feelings of admiration and professional recognition along with worry, insecurity and sadness.

CONCLUSION

The list of primary themes covers what might seem very basic therapeutic interventions. However, the careful and open-minded manner in which these were carried out was noteworthy. The double task of staying closely attuned to the patient's airy reflections and, at the same time, when the patient was ready for it, carefully making links to domains of the patient's everyday life, was clearly molded to patients with fragile attachment.

Psychodynamic psychotherapy: developing the evidence base

Psychodynamic psychotherapy has been criticised as being based on outdated principles of psychoanalysis and lacking an adequate evidence base to convincingly demonstrate its efficacy. This article summarises the recent evidence from high-quality outcome studies to show that psychodynamic psychotherapy is as effective in the treatment of a range of mental disorders as other psychological treatment modalities such as cognitive-behavioural therapy, as well as reviewing process-outcome research aiming to elucidate mechanisms of therapeutic change. A paradigm for psychodynamic psychotherapy research based on attachment theory is introduced, which may inform the development of psychodynamic therapeutic modalities tailored for specific conditions.

LEARNING OBJECTIVES

Supportive psychodynamic psychotherapy for psychosis

The UK National Institute for Health and Care Excellence guidance suggests that psychodynamic principles may be used to understand the experiences of people with psychosis. In this article we consider the application of psychodynamic principles in psychotherapy for psychosis, focusing on one particular model: supportive psychodynamic psychotherapy (SPP). We describe this approach with a detailed fictitious case example and discuss how SPP has developed through significant modifications of classical psychoanalytic therapy and the evidence base for it. We consider its overlap with cognitive–behavioural therapy, its advantages and disadvantages, and the arguments for making SPP available as a treatment option in services for psychosis.

An integrative model of the impairments in insight in schizophrenia: emerging research on causal factors and treatments

INTRODUCTION

Poor insight, or unawareness of some major aspect of mental illness, is a major barrier to wellness when it interferes with persons seeking out treatment or forming their own understanding of the challenges they face. One barrier to addressing impaired insight is the absence of a comprehensive model of how poor insight develops.

AREAS COVERED

To explore this issue we review how poor insight is the result of multiple phenomena which interfere with the construction of narrative accounts of psychiatric challenges, rather than a single social or biological cause. Expert commentary: We propose an integrative model of poor insight in schizophrenia which involves the interaction of symptoms, deficits in neurocognition, social cognition, metacognition, and stigma. Emerging treatments for poor insight including therapies which focus on the development of metacognition are discussed.

The Experience of Childhood Trauma and Its Influence on the Course of Illness in First-Episode Psychosis: A Qualitative Study

Persons with schizophrenia spectrum disorders often report high levels of childhood trauma, which often exacerbates symptoms and impede the process of recovery. However, little is known about how these traumas are experienced by service users and how they are integrated in their life stories. To examine this, we conducted in-depth interviews with 15 service users with a diagnosis of a first-episode nonaffective psychosis who had reported 1 or more childhood traumas in self-report measures. There was an unexpected discrepancy between the number of traumas reported in self-report measures and in semistructured interviews, and many of the traumas did not seem integrated in their personal narratives. The analyses further revealed that although participants often described complicated and traumatic childhood environments, they still felt supported by their families; they reported a range of ways in which they tried to cope with and gain control of their psychotic disorder, and they described a general optimistic view of the future.

An exploration of the therapeutic alliance within a telephone-based cognitive behaviour therapy for individuals with experience of psychosis

OBJECTIVES

This study investigated the therapeutic alliance (TA) between clients and therapists involved in a telephone-based cognitive behaviour therapy (CBT) oriented psychological intervention for individuals experiencing psychosis.

DESIGN

The telephone intervention involved recovery-focused CBT with use of a self-help guide and group intervention co-facilitated by colleagues with personal experience of psychosis. It was delivered as part of a Participant Preference Trial.

METHODS

Twenty-one client/therapist dyads were examined within this study. In addition to a measure of TA, clients completed measures of depression, social functioning, symptom severity, and strength of treatment preference, while therapists completed measures related to the level of shared formulation, therapist confidence, and therapeutic change estimates.

RESULTS

Therapeutic alliance levels were comparable to previously reported face-to-face psychosis intervention studies. Clients consistently reported significantly higher TA ratings compared to therapists. Depression scores and the strength of preference for treatment were significantly associated with client TA. Greater therapist perceived change was associated with higher therapist rated TA, while higher numbers of missed therapy sessions associated with lower therapist ratings.

CONCLUSIONS

Telephone-based psychosis interventions may support the formation of positive relationships that are comparable to the quality of relationships developed between therapists and clients during face-to-face CBT therapy. Methodological limitations including low participant numbers and heightened risk of a Type I error necessitate caution when interpreting findings. Further research into therapist and client variables associated with TA is required.

PRACTITIONER POINTS

Telephone delivered interventions to support people with psychosis-related difficulties can result in the development of a good quality TA between therapists and clients. There is a significant difference between therapist and client ratings of TA. Clients tend to score the quality of the TA significantly more highly than therapists. Providing clients with choice when participating in therapeutic interventions could potentially contribute towards improved TA reporting by clients.

Metacognitive capacities for reflection in schizophrenia: implications for developing treatments

Models of schizophrenia, which focus exclusively on discrete symptoms and neurocognitive deficits, risk missing the possibility that a core feature of the disorder involves a reduced capacity to construct complex and integrated representations of self and others. This column details a new methodology that has been used to assess deficits in the metacognitive abilities that allow persons to form complex ideas about themselves and others and to use that knowledge to respond to psychosocial challenges in schizophrenia. Evidence is summarized supporting the reliability and validity of this method, as well as links this work has revealed between metacognition and psychosocial outcomes. It is suggested that this work points to the need to develop interventions which move beyond addressing symptoms and specific skills, and assist persons to recapture lost or atrophied metacognitive capacity and so form the kind of ideas about themselves and others needed, to move meaningfully toward recovery.

Between self-clarity and recovery in schizophrenia: reducing the self-stigma and finding meaning

Although there are extensive theoretical reviews regarding the self-experience among persons with schizophrenia, there is limited research that addresses the implications of self-clarity on the recovery of persons with schizophrenia while exploring the role of possible mediators within this process. Accordingly, the current study explored the relationship between self-clarity and recovery while examining the possible mediating role of self-stigma and sense of meaning in life. 80 persons with schizophrenia or schizoaffective disorder were administered four scales: self-concept clarity, self-stigma, meaning in life, and recovery. Results confirmed the hypothesized model in which self-clarity affects self-stigma, self-stigma affects meaning in life, and meaning in life affects recovery. No direct relationship was uncovered between self-clarity and recovery. Implications of the current study for future research and clinical practice are discussed with the emphasis on the importance of the self-experience with regard to the process of recovery.

Metacognitive mastery and intrinsic motivation in schizophrenia

Deficits in intrinsic motivation (IM) have been linked to poorer outcome in schizophrenia, but its proximal mechanisms remain poorly understood. This study examined whether metacognitive mastery, or the capacity to use knowledge of self, others, and context to identify and cope with psychological difficulties, predicted levels of IM for 6 months among 75 participants with prolonged schizophrenia. Repeated-measures analysis of variance revealed that high metacognitive mastery predicted consistently higher levels of IM; however, intermediate and low mastery did not produce unique IM profiles. The findings suggest that metacognitive mastery may have an important role in IM over time and could be a meaningful treatment target.

Self-disturbances in schizophrenia: history, phenomenology, and relevant findings from research on metacognition

With a tradition of examining self-disturbances (Ichstörungen) in schizophrenia, phenomenological psychiatry studies the person's subjective experience without imposing theoretical agenda on what is reported. Although this tradition offers promising interface with current neurobiological models of schizophrenia, both the concept of Ichstörung and its history are not well understood. In this article, we discuss the meaning of Ichstörung, the role it played in the development of the concept of schizophrenia, and recent research on metacognition that allows for the quantitative study of the link between self-disturbance and outcome in schizophrenia. Phenomenological psychiatrists such as Blankenburg, Binswanger, and Conrad interpreted the Ichstörung as disturbed relationship to self and others, thus challenging recent efforts to interpret self-disturbance as diminished pure passive self-affection, which putatively "explains" schizophrenia and its various symptoms. Narrative is a reflective, embodied process, which requires a dynamic shifting of perspectives which, when compromised, may reflect disrupted binding of the components of self-experience. The Metacognition Assessment Scale-abbreviated as MAS-A-suggests that persons with schizophrenia tend to produce narratives with reductions in the binding processes required to produce an integrated, embodied self within narrated life stories, and in interactive relationships with others.

Poor insight into schizophrenia: contributing factors, consequences and emerging treatment approaches

Poor insight or unawareness of illness has been commonly observed in schizophrenia and has been long recognized as a potent barrier to treatment adherence and a risk factor for a range of poorer outcomes. Paradoxically, the achievement of insight often poses a different set of problems including depression and low self-esteem. One barrier to the treatment of poor insight has been a lack of understanding of the phenomenon, which causes poor insight to develop and persist over time. Without knowing what promotes poor insight, treatment to date has had little to offer beyond the supportive provision of information. To explore these issues, this article reviews emerging literature on the correlates of poor insight in schizophrenia, and newly developing ways of conceptualizing insight. It then details a number of innovative integrative group and individual treatment approaches in the early stages of development, which take into account some of the potential causal forces behind poor insight, including deficits in neurocognition, social cognition, metacognition and heightened self-stigma. A plan for further research is presented to develop a model of the factors whose interaction influences insight, and to refine and test integrative treatments.

Do persons with schizophrenia who have better metacognitive capacity also have a stronger subjective experience of recovery?

Research suggests that persons with schizophrenia experience deficits in the ability to synthesize complex and integrated representations of themselves and others. While impairments in these metacognitive capacities are hypothetically related to the ability to make sense of the challenges of schizophrenia, little is known about their relationship with the subjective experience of recovery from mental illness. To examine this question, this study investigated whether persons with stronger self-reported recovery had better metacognitive capacity, after controlling for severity of psychiatric symptoms. Forty-six outpatients with schizophrenia spectrum disorders who were taking part in a study of the Illness Management and Recovery program were concurrently administered the Recovery Assessment Scale, the Positive and Negative Syndrome Scale, and the Indiana Psychiatric Illness Interview which was scored using the Abbreviated Metacognitive Assessment Scale. Analysis of covariance revealed that metacognitive capabilities reflecting self-reflectivity and decentration were differentially related to several components of recovery beyond the effects of psychiatric symptoms. The metacognitive abilities to think about oneself in a sophisticated way and form integrated ideas about oneself and others within the larger world, understanding that none are the metaphorical center are present in individuals holding strong perceptions of recovery.

Synthetic metacognition as a link between brain and behavior in schizophrenia

Deficits in metacognitive capacity in schizophrenia can be conceptualized as existing along a spectrum from more discrete to more synthetic activities. These capacities may be of great importance in schizophrenia research given their potential to mediate and moderate the impact of illness-related factors on outcome. To explore this possibility this review summarizes research on synthetic metacognition using a paradigm in which metacognitive capacity is rated on the basis of spontaneously produced personal narratives. Evidence from a review of the literature shows that these deficits are detectable in patients with schizophrenia and are related to, but not reducible to, symptom severity and poorer neurocognitive function. Independent of symptoms and neurocognition, deficits in synthetic metacognition, which are likely linked to the brain’s ability to integrate information, are related to a range of outcomes including functional competence, learning potential, and insight. These deficits may also play a role in long term psychosocial functioning via their impact on the ability to sustain social functions.