Metacognition and Intersubjectivity: Reconsidering Their Relationship Following Advances From the Study of Persons With Psychosis

Conceptual disorganization as a mediating variable between visual learning and metacognition in schizophrenia

Objectives

The aim of this study was to evaluate the relative contributions of visual learning and conceptual disorganization to specific metacognitive domains in a sample of outpatients with stable schizophrenia.

Methods

A total of 92 consecutive outpatients with stable schizophrenia were recruited in a cross-sectional study. We analyzed the data with five path analyses based on multiple regressions to analyze the specific effect of visual learning on metacognitive capacity and metacognitive domains and the possible mediating role of conceptual disorganization.

Results

We found that (i) visual learning was negatively correlated to metacognitive capacity and its domains on the one hand and conceptual disorganization on the other hand; (ii) conceptual disorganization was negatively associated with metacognition and its domains; and (iii) when the mediation effect was considered, conceptual disorganization fully mediated the relationship between visual learning and mastery, whereas it served as a partial mediator of the effect of visual learning on the other metacognition domains, i.e., self-reflectivity, understanding others' mind, and decentration.

Conclusion

These results delineate an articulated panorama of relations between different dimensions of metacognition, visual learning, and conceptual disorganization. Therefore, studies unable to distinguish between different components of metacognition fail to bring out the possibly varying links between neurocognition, disorganization, and metacognition.

A dyadic session-by-session assessment of therapeutic alliance and short-term outcome among clients with schizophrenia in comparison with clients with emotional disorders

OBJECTIVE

Although the clinical significance of the therapeutic alliance (TA) is well documented, the literature regarding the establishment of TA and the relation between client-therapist agreement on it to short-term outcome among various diagnostic groups-and specifically among clients diagnosed with serious mental illness (SMI)-is sparse. The aim of the present study was to examine the effect of client diagnosis on the abovementioned TA characteristics.

METHOD

Dyadic analyses of session-by-session (SBS) data were used to compare clients diagnosed with schizophrenia and clients diagnosed with emotional disorders (based on a clinical interview) in their TA characteristics.

RESULTS

TA as initially rated by clients was stronger in the emotional disorders group than in the schizophrenia group. Higher TA ratings, regardless of whether these were provided by the therapist or the client, predicted better subsequent functioning in the emotional disorders group, whereas in the schizophrenia group, this association was observed only among good-outcome cases.

CONCLUSIONS

Establishing TA, having client-therapist agreement on it, and having clients derive therapeutic benefit from it might be more challenging with clients with schizophrenia than with clients with emotional disorders. Special attention should be given to specific challenges and needs regarding clients' diagnosis in order to enhance favourable therapy outcomes.

Findings from a randomized controlled trial of Metacognitive Reflection and Insight Therapy for people with schizophrenia: Effects on metacognition and symptoms

BACKGROUND

Research has suggested that people diagnosed with schizophrenia experience challenges in their abilities to reflect upon themselves, others and their actions in the world. One emerging approach to addressing these forms of subjective disturbance is Metacognitive Reflection and Insight Therapy (MERIT).

AIMS

In this study, a randomized delayed trial was conducted to assess the effects of MERIT upon metacognition, psychiatric symptoms and quality of life.

MATERIALS AND METHODS

Following recruitment and randomization, data from 54 adults diagnosed with schizophrenia were analysed.

RESULTS

Findings included significant interaction effects between group (immediate intervention or waiting condition) and time (pre- and post intervention) with regard to the metacognition general score and its domain of mastery, as well as with regard to negative, positive and cognitive symptoms.

DISCUSSION

Participating in MERIT seems to improve one's ability to use reflective knowledge to cope with psychological challenges and to improve, or at least maintain, level of symptomatology.

CONCLUSIONS

These findings are discussed within the framework of agency as an important aspect of recovery.

Mentalizing in the context of Mentzos' dilemma-on the use of implicit work in the treatment of non-affective psychosis

Current approaches to the treatment of non-affective psychosis include elements of mentalization-based treatment and the potential in enhancing mentalizing capacity in this patient group has been widely emphasized. This article presents the "psychotic identity dilemma", a concept by Stavros Mentzos, and a therapeutic approach considering this concept as a valuable complementary addition to these treatments. The idea of a dilemma between closeness and distance, which in itself cannot be represented mentally at first, helps to respond to specific needs of patients with psychotic disorders by placing the treatment focus on fundamental interpersonal processes. Following this train of thought, this article attempts to shed light on the importance of the "real relationship" between therapist and patient as well as the exploration of the "here and now", especially at the beginning of psychotherapeutic treatment. Two treatment modes are suggested, one characterized by the experience of interpersonality within the therapeutic relationship and a second one characterized by the reflection of interpersonal phenomena. These modes are framed by Stavros Mentzos' concept of an identity dilemma. We describe how mentalizing first needs to be addressed implicitly in a tolerable, exemplary relationship in which closeness and distance are regulated based on the therapist's countertransference, then explicitly. A series of interventions are described, which allow for moments of shared attention, promote intentionality and contingency and, later in the course of therapy, help to integrate experiences into narratives.

A pilot randomized controlled trial comparing a novel compassion and metacognition approach for schizotypal personality disorder with a combination of cognitive therapy and psychopharmacological treatment

BACKGROUND

Schizotypal personality disorder is characterized by a pervasive pattern of maladaptive behavior that has been associated with the liability for schizophrenia. Little is known about effective psychosocial interventions. This pilot non-inferiority randomized controlled trial aimed to compare a novel form of psychotherapy tailored for this disorder and a combination of cognitive therapy and psychopharmacological treatment. The former treatment - namely, Evolutionary Systems Therapy for Schizotypy-integrated evolutionary, metacognitively oriented, and compassion focused approaches.

METHODS

Thirty-three participants were assessed for eligibility, twenty-four randomized on a 1:1 ratio, nineteen included in the final analysis. The treatments lasted 6 months (24 sessions). The primary outcome was change across nine measurements in personality pathology, the secondary outcomes were remission from diagnosis and pre-post changes in general symptomatology and metacognition.

RESULTS

Primary outcome suggested a non-inferiority of the experimental treatment in respect to control condition. Secondary outcomes reported mixed results. There was no significant difference in terms of remission, but experimental treatment showed a larger reduction of general symptomatology (η² = 0.558) and a larger increase in metacognition (η² = 0.734).

CONCLUSIONS

This pilot study reported promising results about the effectiveness of the proposed novel approach. A confirmatory trial on large sample size is needed to provide evidence about relative effectiveness of the two treatment conditions.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT04764708; Registration day 21/02/2021.

Metacognitive Reflection and Insight Therapy (MERIT) Delivered Virtually During the COVID-19 Pandemic: An Illustration of Two Cases

Alternative platform offerings for psychotherapy have become a necessity in the age of the novel coronavirus (COVID-19) pandemic. The current study describes the virtual adaptation of Metacognitive Reflection and Insight Therapy (MERIT) for people with psychosis. MERIT is a recovery-oriented psychotherapy that has shown promise in increasing metacognition and allowing individuals to make meaning of their psychiatric challenges and direct their own recovery efforts. MERIT delivery requires the assumption that metacognitive reflection is an intersubjective act where individuals make meaning with others instead of in isolation. As such, considering the current COVID-19 pandemic, research is needed to understand how intersubjectivity and the therapeutic alliance may differ in a virtual environment rather than in-person. The present study addresses this question by illustrating two case examples of MERIT's adaptation to a virtual delivery telehealth format. Moreover, this study expands on Lysaker and colleagues' (2020) investigation of virtual adaptations of MERIT by exploring how MERIT is adapted in a virtual environment, how intersubjectivity changes in a virtual environment, and, what opportunities virtual platforms allow for metacognitive reflection. Overall, we found that MERIT can be successfully delivered in a virtual telehealth platform. We discuss opportunities and considerations for MERIT and other psychotherapy virtual delivery.

Exploring the Latent Structure and Convergent and Incremental Validity of the Metacognition Assessment Scale - Abbreviated in a Sample of Patients with Non-Affective Psychosis

Synthetic metacognition is a heterogeneous construct related to psychotic disorders. One important tool to assess this construct is the Metacognition Assessment Scale - Abbreviated (MAS-A). In this study, we investigated the latent structure as well as the interrater reliability and convergent and incremental validity of the MAS-A in a sample of patients with non-affective psychosis. Analyses indicated that the scale might be one-dimensional. Interrater reliability of the MAS-A total score was good. In terms of convergent validity, correlational analyses showed significant associations of MAS-A metacognition with the Operationalized Psychodynamic Diagnosis Level of Structural Integration Axis (OPD-LSIA) and the Levels of Emotional Awareness Scale (LEAS). In terms of construct validity, a significant association was observed between MAS-A metacognition and a short version of the International Classification of Functioning, Disability and Health (MINI-ICF), which persisted after self-report measures of impairments in structural capacities (Structure Questionnaire of Operationalized Psychodynamic Diagnosis [OPD-SQS]) and mentalizing abilities (Mentalization Questionnaire [MZQ]) were included as covariates, but not after symptom dimensions were included. There was a significant correlation with the current living situation, but not with other external criteria like diagnosis or duration of illness. Future studies should explore alternative outcomes and replicate results in longitudinal designs.

Metacognition in schizophrenia: A practical overview of psychometric metacognition assessment tools for researchers and clinicians

Metacognition refers to the cognitive ability to control, monitor and modulate cognitive processes thus guiding and orienting behavior: a continuum of mental activities that ranges from more discrete ones, such as the awareness of the accuracy of others' judgment, to more integrated activities, such as the knowledge of cognitive processes. Metacognition impairment in schizophrenia, which is considered a core feature of the illness, has become a growing research field focusing on a wide range of processes including reasoning, autobiographical memory, memory biases, cognitive beliefs and clinical insight. There is a well-established relationship between metacognition and schizophrenia symptoms severity, as well as between impaired metacognitive functioning and specific symptomatic sub-domains, such as positive symptoms, negative symptoms, or disorganization. The development of specific cognitive-derived psychotherapies for metacognitive deficits in schizophrenia has been ongoing in the last years. Although sharing a metacognitive feature, these treatments focus on different aspects: false or unhelpful beliefs for metacognitive therapy; cognitive biases for metacognitive training; schematic dysfunctional beliefs for cognitive behavioral therapy (CBT) for psychoses; metacognitive knowledge and sense of identity for MERIT; interpersonal ideas or events triggering delusional thinking for MIT-P. This article reviews the instruments designed to assess metacognitive domains and functions in individuals with schizophrenia, providing mental health professionals with an overview of the heterogeneous current scenario ranging from self-administered scales to semi-structured interviews, which are supported by a variety of theoretical frameworks. Future directions may address the need for more specific and refined tools, also able to follow-up psychotherapeutic-induced improvements.

Social Perception Deficit as a Factor of Vulnerability to Psychosis: A Brief Proposal for a Definition

Disturbances in social cognition are a core feature of schizophrenia. While most research in the field has focused on emotion perception, social knowledge, theory of mind, and attribution styles, the domain of social perception has received little specific attention. In this paper, we suggest that this issue can be explained by the lack of a precise and unitary definition of the concept, this leads to the existence of different competing uses of the concept and their conflation with other domains of social cognition. Relying on resources coming from the ecological approach to psychology and the phenomenological tradition in psychiatry, we propose that the concept of Social Perception should be used to refer to low-level pre-reflective processes underlying the awareness of interpersonal interactions with and between others. Clinical data suggests that people with schizophrenia have problems perceiving social situations as opportunities for social engagement, so, in order to fulfil this explanatory need, we propose that the term should be used to capture this important-yet neglected-domain of social cognition. We conclude with the discussion of some future directions for research derived from our proposal.

Centrality and Decentration: A Model for Understanding Disturbances in the Relationship of the Self to the World in Psychosis

ABSTRACT

A considerable body of phenomenological research has described different ways in which the relationship of the person to the world in psychosis is affected. This literature, however, has lacked an accepted unifying theoretical model and means of quantitatively measuring these disturbances. To address this, the current article seeks to integrate a novel phenomenological model of psychosis offered by Henri Grivois, which is explicitly concerned with centrality or a person's sense of being the center of all things, with empirical research on the integrative model of metacognition, which allows for measurements of decentration or the degree to which persons can form integrated ideas about their place in their larger community. It is proposed that this literature may allow for a model of how psychotherapy can address centrality through the building of intersubjectivity and enhancing metacognition.

The prefrontal cortex and (uniquely) human cooperation: a comparative perspective

Humans have an exceptional ability to cooperate relative to many other species. We review the neural mechanisms supporting human cooperation, focusing on the prefrontal cortex. One key feature of human social life is the prevalence of cooperative norms that guide social behavior and prescribe punishment for noncompliance. Taking a comparative approach, we consider shared and unique aspects of cooperative behaviors in humans relative to nonhuman primates, as well as divergences in brain structure that might support uniquely human aspects of cooperation. We highlight a medial prefrontal network common to nonhuman primates and humans supporting a foundational process in cooperative decision-making: valuing outcomes for oneself and others. This medial prefrontal network interacts with lateral prefrontal areas that are thought to represent cooperative norms and modulate value representations to guide behavior appropriate to the local social context. Finally, we propose that more recently evolved anterior regions of prefrontal cortex play a role in arbitrating between cooperative norms across social contexts, and suggest how future research might fruitfully examine the neural basis of norm arbitration.

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

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

Emerging psychotherapeutic approaches to addressing self-experience in schizophrenia spectrum disorders

Growing awareness that many who are diagnosed with schizophrenia recover has spurred the development of new psychosocial approaches to treatment. These new approaches include forms of individual and group psychotherapy whose focus extends beyond reducing symptoms and improving skills to subjective outcomes related to sense of self. This paper introduces an issue of In Session which presents six case reports which illustrating these approaches in differing international contexts. First, we explore the larger issues of subjective outcomes from schizophrenia. We then discuss each of the papers separately along with implications of these papers as a group for how treatment might promote the recapturing of a sense of self or place in the world.

Deficits in access consciousness, integrative function, and consequent autonoetic thinking in schizophrenia

Alterations within consciousness in schizophrenia can be evidenced by impediments in self-awareness and loss of agency. Ned Block's definition of access consciousness is applied in order to further delineate cognitive deficits involving reflective thought and autonoetic thinking in persons with schizophrenia. Current theories on the nature and functioning of consciousness are discussed, which include Global Workspace Theory and metarepresentational characterizations. These describe a recursive, integrative quality to consciousness, contributed to by the functions of access consciousness, that is relevant in examining cognitive deficits in schizophrenia. The integrative deficit that is described as operating in conscious process involves a failure to incorporate prior outputs from a separate cognitive task and integrate these into a novel working schema. The alterations in access consciousness in persons with schizophrenia appear to be a consequence of disrupted integrative cognitive functions. An anteceding problem with cortical circuits involving integrative functions related to access consciousness is therefore hypothesized to manifest as subsequent cognitive dysfunction that leads to symptoms of schizophrenia. Constitutive failures to integrate information in schizophrenia could lead to an inability to create experiential unity and manage content in autonoetic consciousness. Some of the aberrant reasoning manifested by persons with schizophrenia, including problems with hierarchical relational reasoning, model-based-learning, J-con, ipseity, and source monitoring, could also reflect alterations in access consciousness, and their investigation offers additional approaches for scientific inquiry.

Metacognition, social cognition, and mentalizing in psychosis: are these distinct constructs when it comes to subjective experience or are we just splitting hairs?

Research using the integrated model of metacognition has suggested that the construct of metacognition could quantify the spectrum of activities that, if impaired, might cause many of the subjective disturbances found in psychosis. Research on social cognition and mentalizing in psychosis, however, has also pointed to underlying deficits in how persons make sense of their experience of themselves and others. To explore the question of whether metacognitive research in psychosis offers unique insight in the midst of these other two emerging fields, we have offered a review of the constructs and research from each field. Following that summary, we discuss ways in which research on metacognition may be distinguished from research on social cognition and mentalizing in three broad categories: (1) experimental procedures, (2) theoretical advances, and (3) clinical applications or indicated interventions. In terms of its research methods, we will describe how metacognition makes a unique contribution to understanding disturbances in how persons make sense of and interpret their own experiences within the flow of life. We will next discuss how metacognitive research in psychosis uniquely describes an architecture which when compromised - as often occurs in psychosis - results in the loss of persons' sense of purpose, possibilities, place in the world and cohesiveness of self. Turning to clinical issues, we explore how metacognitive research offers an operational model of the architecture which if repaired or restored should promote the recovery of a coherent sense of self and others in psychosis. Finally, we discuss the concrete implications of this for recovery-oriented treatment for psychosis as well as the need for further research on the commonalities of these approaches.

Common and differential dimensions of personal identity between psychosis and depression: The relevance of gender and depressive mood

Disturbances in personal identity are recognized in psychosis and depression. However, it is unknown whether these disruptions share common processes across clinical groups, or whether there are unique alterations by group or between men and women within each clinical group. To advance on this question, we compared personal identity dimensions in psychosis and depression and investigated the effects of gender and depressive mood. This study assessed dimensions of personal identity using the repertory grid technique among 85 outpatients with psychosis, 85 outpatients with depressive disorders and 85 healthy controls who were matched by age. Data regarding depressive mood and general functioning was also collected. Results showed that self-discrepancies were higher in psychosis and depression than in controls, and were associated with depressive mood. Interpersonal dichotomous thinking was more prevalent in women in both clinical groups. Women with psychosis showed higher ideal-others discrepancy and had a more complex structure of personal identity than their male counterparts. To conclude, alterations in self-ideal and self-others discrepancies may be transdiagnostic dimensions related to depressive mood. Interpersonal dichotomous thinking may also be a common dimensional characteristic in psychosis and depression but more specific to women. Finally, critical views of others and a higher complexity of personal identity may be more specific to women than men with psychosis. Our results are consistent with other studies pointing to the need for person-focused treatments promoting the recovery of a full sense of personal identity, rather than just focusing on specific thoughts and feelings.