Metacognitive Reflection and Insight Therapy (MERIT) With a Patient With Severe Symptoms of Disorganization

The Recovery Process for Individuals With Schizophrenia in the Context of Evidence-Based Psychotherapy and Rehabilitation

Abstract. This systematic review aimed to evaluate the efficacy of Cognitive Behavioral Therapy (CBT), META Cognitive Therapy (MCT), Metacognitive Training (MCTR), Metacognitive Reflection and Insight Therapy (MERIT), of various rehabilitation programs and of recovery programs in schizophrenia. Medline/Pubmed was searched for studies published in English from January 2010 to August 2018, which were screened against inclusion criteria by two reviewers. The methodological quality of the included studies was evaluated by two independent raters, which are the Effective Public Health Practice Project (EPHPP) quality assessment tool for quantitative studies and the fidelity criteria. The study included 41 RCTs and 12 case studies with n = 3,059 persons with schizophrenia. Cognitive Behavioral Therapy (CBT) proved to be superior in terms of the improvement of primary and secondary outcomes. MCT decreased positive symptoms and improved metacognitive capacity and insight. MCTR reduced positive symptoms and socially disruptive behavior. MERIT improved metacognitive capacity and insight. Rehabilitation programs were efficacious in the improvement of cognition, symptoms, and functional outcome. The recovery programs enhanced illness-management knowledge, attitudes toward medication and insights related to negative symptoms. It is recommended to combine the above evidence based psychotherapeutic interventions. Limitations of this systematic review are discussed toward the end of the essay. Some important factors have to be considered in the future have been mentioned.

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.

Metacognitive Reflection and Insight Therapy: A Recovery-Oriented Treatment Approach for Psychosis

Recent research has suggested that recovery from psychosis is a complex process that involves recapturing a coherent sense of self and personal agency. This poses important challenges to existing treatment models. While current evidence-based practices are designed to ameliorate symptoms and skill deficits, they are less able to address issues of subjectivity and self-experience. In this paper, we present Metacognitive Insight and Reflection Therapy (MERIT), a treatment approach that is explicitly concerned with self-experience in psychosis. This approach uses the term metacognition to describe those cognitive processes that underpin self-experience and posits that addressing metacognitive deficits will aid persons diagnosed with psychosis in making sense of the challenges they face and deciding how to effectively manage them. This review will first explore the conceptualization of psychosis as the interruption of a life and how persons experience themselves, and then discuss in more depth the construct of metacognition. We will next examine the background, practices and evidence supporting MERIT. This will be followed by a discussion of how MERIT overlaps with other emerging treatments as well as how it differs. MERIT's capacity to engage patients who reject the idea that they have mental illness as well as cope with entrenched illness identities is highlighted. Finally, limitations and directions for future research are discussed.

Predicting therapy success from the outset: The moderating effect of insight into the illness on metacognitive psychotherapy outcome among persons with schizophrenia

The degree to which a person recognizes their mental disorder, attributes symptoms to the disorder, and recognizes that treatment may be necessary is frequently referred to as clinical insight. The current study investigates whether clinical insight at baseline moderates the effects on metacognitive capacity of 40 sessions of metacognitive reflection and insight therapy among 35 participants with psychosis. Findings showed that clinical insight did not predict drop-out from therapy. Multilevel analyses provided support for our hypotheses that insight at baseline significantly moderates metacognitive gains at both postmeasurement and follow-up. Our findings demonstrate that lacking clinical insight substantially hampers the effect of this psychosocial intervention. We posit that research efforts should shift from developing interventions, which enhance clinical insight, to interventions, which are effective in absence of clinical insight.

Metacognitive function and fragmentation in schizophrenia: Relationship to cognition, self-experience and developing treatments

Bleuler suggested that fragmentation of thought, emotion and volition were the unifying feature of the disorders he termed schizophrenia. In this paper we review research seeking to measure some of the aspects of fragmentation related to the experience of the self and others described by Bleuler. We focus on work which uses the concept of metacognition to characterize and quantify alterations or decrements in the processes by which fragments or pieces of information are integrated into a coherent sense of self and others. We describe the rationale and support for one method for quantifying metacognition and its potential to study the fragmentation of a person's sense of themselves, others and the relative place of themselves and others in the larger human community. We summarize research using that method which suggests that deficits in metacognition commonly occur in schizophrenia and are related to basic neurobiological indices of brain functioning. We also present findings indicating that the capacity for metacognition in schizophrenia is positively related to a broad range of aspects of psychological and social functioning when measured concurrently and prospectively. Finally, we discuss the evolution and study of one therapy that targets metacognitive capacity, Metacognitive Reflection and Insight Therapy (MERIT) and its potential to treat fragmentation and promote recovery.

Metacognitive reflection and insight therapy (MERIT) for patients with schizophrenia

BACKGROUND

Impaired metacognition is associated with difficulties in the daily functioning of people with psychosis. Metacognition can be divided into four domains: Self-Reflection, Understanding the Other's Mind, Decentration, and Mastery. This study investigated whether Metacognitive Reflection and Insight Therapy (MERIT) can be used to improve metacognition.

METHODS

This study is a randomized controlled trial. Patients in the active condition (n = 35) received forty MERIT sessions, the control group (n = 35) received treatment as usual. Multilevel intention-to-treat and completers analyses were performed for metacognition and secondary outcomes (psychotic symptomatology, cognitive insight, Theory of Mind, empathy, depression, self-stigma, quality of life, social functioning, and work readiness).

RESULTS

Eighteen out of 35 participants finished treatment, half the drop-out stemmed from therapist attrition (N = 5) or before the first session (N = 4). Intention-to-treat analysis demonstrated that in both groups metacognition improved between pre- and post-measurements, with no significant differences between the groups. Patients who received MERIT continued to improve, while the control group returned to baseline, leading to significant differences at follow-up. Completers analysis (18/35) showed improvements on the Metacognition Assessment Scale (MAS-A) scales Self Reflectivity and metacognitive Mastery at follow-up. No effects were found on secondary outcomes.

CONCLUSIONS

On average, participants in the MERIT group were, based on MAS-A scores, at follow-up more likely to recognize their thoughts as changeable rather than as facts. MERIT might be useful for patients whose self-reflection is too limited to benefit from other therapies. Given how no changes were found in secondary measures, further research is needed. Limitations and suggestions for future research are discussed.

A Disorder by Any Other Name: Metacognition, Schizophrenia, and Diagnostic Practice

Humanistic psychology has made us aware that any understanding of schizophrenia must see persons diagnosed with this condition as whole persons who are making sense of what wellness and recovery mean to them. This has raised questions about what the diagnosis of schizophrenia means and whether the diagnostic label of schizophrenia is helpful when we try to conceptualize the actions and aims of treatment. To examine this issue we propose it is essential to consider what is systematically occuring psychologicaly in recovery when persons experience, interpret and agentically respond to emerging challenges. We then review how the integrated model of metacognition provides a systematic, person-centered, evidence-based approach to understanding psychological processes which impact recovery, and discuss how this guides a form of psychotherapy, metacognitive reflection and insight therapy, which promotes metacognitive abilities and support recovery. We suggest this work indicates that metacognitive capacity is something that can be diagnosed without stigmatizing persons. It can be used to meaningfully inform clinical practice across various theoretical models and offers concrete implications for rehabilitation.

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.

Aspects of Theory of Mind that attenuate the relationship between persecutory delusions and social functioning in schizophrenia spectrum disorders

BACKGROUND AND OBJECTIVES

Despite the apparent relevance of persecutory delusions to social relationships, evidence linking these beliefs to social functioning has been inconsistent. In this study, we examined the hypothesis that theory of mind moderates the relationship between persecutory delusions and social functioning.

METHODS

88 adults with schizophrenia or schizoaffective disorder were assessed concurrently for social functioning, severity of persecutory delusions, and two components of theory of mind: mental state decoding and mental state reasoning. Mental state decoding was assessed using the Eyes Test, mental state reasoning using the Hinting Task, and social functioning assessed with the Social Functioning Scale. Moderation effects were evaluated using linear models and the Johnson-Neyman procedure.

RESULTS

Mental state reasoning was found to moderate the relationship between persecutory delusions and social functioning, controlling for overall psychopathology. For participants with reasoning scores in the bottom 78th percentile, persecutory delusions showed a significant negative relationship with social functioning. However, for those participants with mental state reasoning scores in the top 22nd percentile, more severe persecutory delusions were not significantly associated with worse social functioning. Mental state decoding was not a statistically significant moderator.

LIMITATIONS

Generalizability is limited as participants were generally men in later phases of illness.

CONCLUSIONS

Mental state reasoning abilities may buffer the impact of persecutory delusions on social functioning, possibly by helping individuals avoid applying global beliefs of persecution to specific individuals or by allowing for the correction of paranoid inferences.

The developmental origins of metacognitive deficits in schizophrenia

The deficits in metacognition have been observed in schizophrenia but developmental roots of impaired metacognition are not well understood. Accordingly, this study compared metacognitive abilities of patients with schizophrenia and healthy group and examined the relationship between childhood trauma, attachment style and caregiver attitudes with metacognitive capacity which might contribute to metacognitive deficits in patient group. 35 patients with schizophrenia and 35 healthy people were included in the study. Metacognitive capacity was measured using the Metacognition Assessment Scale Abbreviated (MAS-A). This scale comprises four domains: self-reflectivity, understanding other's mind, decentration and mastery. Group comparisons revealed that schizophrenia patients had greater deficits in metacognitive ability. We found that the report of childhood emotional abuse, a pattern of anxious attachment and over protection by caregivers were uniquely related to metacognitive capacity.

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.

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.

Metacognitive Reflection and Insight Therapy (MERIT) with a Patient with Persistent Negative Symptoms

Metacognition comprises a spectrum of mental activities involving thinking about thinking. Metacognitive impairments may sustain and trigger negative symptoms in people with schizophrenia. Without complex ideas of the self and others, there may be less reason to pursue goal-directed activities and less ability to construct meaning in daily activities, leading to the experience of negative symptoms. As these symptoms tend to be nonresponsive to pharmacotherapy and other kinds of treatment metacognition might be a novel treatment target; improvement of metacognition might lead to improvements in negative symptoms. One therapy that seeks to promote metacognition is the Metacognitive Reflection and Insight Therapy (MERIT). In this study, a case is presented in which a first episode patient with severe negative symptoms is treated with MERIT. A case illustration and the eight core principles of MERIT are presented. Independent assessments of metacognition and negative symptoms before and after therapy show a significant increase of metacognition and decrease of negative symptoms over the course of 40 weeks.