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).

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.

Analysis of a schizophrenic psychosocial network

The amorphous concept of social support systems merits construction of a conceptually coherent theoretical model linked to social theory and amenable to empirical investigation. The social network paradigm is presented as such a model. The model is further defined in terms of the intimate psychosocial network, which has been empirically studied with the Pattison Psychosocial Kinship Inventory. The characteristics of the normal network are shown to differ substantially in the schizophrenic network. The structure and functions of the schizophrenic network are illustrated in a case study analysis. The schizophrenic network is shown to exhibit dynamics that generate and perpetuate psychotic behavior. A strategy for network intervention is described, based on the model of structural change in the network social system.

"Ex-Gays": Religiously mediated change in homosexuals

The authors evaluated 11 white men who claimed to have changed sexual orientation from exclusive homosexuality to exclusive heterosexuality through participation in a pentecostal church fellowship. Religious ideology and a religious community offered the subjects "folk therapy" experience that was paramount in producing their change. On the average their self-identification as homosexual occurred at age 11, their change to heterosexual identification occurred at age 23, and their period of heterosexual identification at the time of this study was 4 years. The authors report 8 men became emotionally detached from homosexual identity in both behavior and intrapsychic process; 3 men were functionally heterosexual with some evidence of neurotic conflict. On the Kinsey 7-point sexual orientation scale all subjects manifested major before-after changes. Corollary evidence suggests that the phenomenon of substantiated changed in sexual orientation without explicit treatment and/or long-term psychotherapy may be more more common than previously thought.

Studies on metabolism and effects of estrogen on pituitary prolactin and LH secretion

The effect of a subcutaneous injection of estradiol on the secretion of pituitary prolactin in the rat and the relationship between serum estradiol level and luteinizing hormone (LH) secretion in mare were reviewed. In addition, the effect of estradiol injection on LH secretion and the metabolism of [14C] estradiol in intact and bile duct fistulated pony mares were studied. Low (0.1 mug/day/rat) to moderate dose (5 mug/day/rat) of estradiol benzoate injected subcutaneously to mature or immature rats significantly increased pituitary content of prolactin and serum prolactin level five- to tenfold. On the other hand, high dose of estradiol (10 mug/day/rat or more) was less effective in stimulating prolactin secretion, and it appeared that progesterone injected concurrently with estradiol had some inhibitory action on the stimulatory effect of estradiol. Studies in pony mares showed that the physiologic level of serum estradiol during proestrus was important for the induction of the ovulatory surge of LH. Intramuscular injection of a low dose (2 or 4 mg/mare) of estradiol was stimulatory, whereas a high dose (8 mg/mare) was inhibitory for LH secretion in pony mares. Results of the estradiol metabolism studies indicated a relatively long half-life for estradiol in the mare. The majority of the [14C] estradiol metabolites appeared in the urine within 24 hr following intravenous injection. Enterohepatic circulation appeared to be important for estradiol metabolism in mare.

Effects of ovariectomy and ovarian hormones on RNA base ratios in specific rabbit brain areas

SUMMARY

The ribonucleic acid (RNA) base percentages were estimated in the hypothalamus, amygdala, hippocampus, frontal cortex, cerebellum and spinal cord of adult intact female rabbits, and after ovariectomy followed by replacement therapy with oestradiol-17β, progesterone and oestradiol plus progesterone. The results indicate a lack of effect on the spinal cord, but a variable effect on all other brain regions examined. In response to the various treatments, all regions examined produced RNA very rich in guanosine monophosphate indicating synthesis of specific RNA. The hypothalamus showed the most significant overall changes. Progesterone injections resulted in the most persistent effects of the hormonal treatments employed. Hypotheses are proposed to explain the variable hormonal effects on brain RNA base composition. It is suggested that ovarian hormones produce specific molecular changes in nervous tissue related either to 'receptors' for the hormones or to neural functions related to behavioural phenomena which are mediated by these hormones.

Effects of amygdaloid lesions on regional brain RNA base ratios

Bilateral lesions produced by electrocoagulation in the basolateral and medial amygdaloid nuclei, subtotal amygdalectomy as well as implants of actinomycin D and cholesterol were all found to have profound effects on brain ribonucleic acid (RNA) base percentages and ratios. The most consistent effect was that on the pituitary and was produced by all treatments. Generally, the hypothalamus and frontal cortex showed varying effects due to the treatments, but the cerebellum uniformly showed no responses to the various treatments. Lesions placed in the medial amygdaloid complex and subtotal amygdalectomy had the greatest effect in changing the RNA base ratio. The bases adenosine monophosphate (AMP), cytidine monophosphate (CMP), guanosine monophosphate (GMP), and uridine monophosphate (UMP) were found to be the most affected. The newly synthesized RNA was found to be rich in UMP and deficient in AMP and CMP when compared to normal animal brain tissue. The assumption is made that lesions in the amygdala bring about an activation or stimulation of a genomic nature to produce specific RNA for a particular neural function.