Comparing Metacognition and Mentalization and Their Implications for Psychotherapy for Individuals with Psychosis

Diverging effects of mentalization based treatment for patients with borderline personality disorder and schizophrenia: an explorative comparison

Introduction

There is robust evidence that both patients with schizophrenia (SCZ) and borderline personality disorder (BPD) display mentalizing difficulties. Less is known however about differences in the way mentalization based treatment (MBT) impacts mentalizing capacity in SCZ and BPD patients. This study compares the impact of MBT on mentalizing capacity in individuals with SCZ and BPD.

Method

The thematic apperception test was used to measure mentalizing capacity. It was administered at the beginning and end of treatment to 26 patients with SCZ and 28 patients with BPD who enrolled in an 18-month long MBT program. For comparison a sample of 28 SCZ patients who did not receive MBT was also included. Using the social cognition and object-relations system, these narratives were analyzed and scored. Missing data was imputed and analyzed using intention-to-treat ANCOVAs with post-treatment measures of mentalizing capacity as dependent variables, group type as independent variable and baseline mentalizing capacities as covariates.

Results

Results showed that patients with BPD showed significantly more improvement on several measures of mentalizing, including complexity of representation (ηp2 = 0.50, ppooled < 0.001), understanding of social causality (ηp2 = 0.41, ppooled < 0.001) and emotional investment in relationships (ηp2 = 0.41, ppooled < 0.001) compared to patients with SCZ who received MBT. No differences were found regarding affect-tone of relationships (ηp2 = 0.04, ppooled = 0.36). SCZ patients who received MBT showed greater performance on understanding of social causality (ηp2 = 0.12, ppooled = 0.01) compared to SCZ patients who did not receive MBT, but no differences were observed on complexity of representations, capacity for emotional investment or affect-tone of relationships.

Discussion

Patients with BPD performed better after receiving MBT on three dimensions of mentalizing capacity than SCZ patients who received MBT. Remarkably, SCZ patients who received MBT performed better on one dimension of mentalizing capacity compared to SCZ patients who did not receive MBT. Whereas MBT for BPD clearly involves improvement on most aspects of mentalizing, MBT for SCZ seems to thwart a further decline of other-oriented, cognitive mentalizing. Treatment goals should be adapted toward these disorder-specific characteristics.

Exploring and Deepening the Facets of Mentalizing: The Integration of Network and Factorial Analysis Approaches to Verify the Psychometric Properties of the Multidimensional Mentalizing Questionnaire (MMQ)

Mentalization is a complex and multifaceted trans-theoretical and trans-diagnostic construct that has found increasing application in the clinical context. This research aimed at deepening the psychometric properties of the Multidimensional Mentalizing Questionnaire (MMQ), a 33-item theoretically based self-report questionnaire allowing for a comprehensive assessment of mentalizing, by integrating factor analysis and network analysis approaches. A sample of 1640 participants (M_age = 33 years; SD = 13.28) was involved in the research. The six-factor structure was confirmed for the MMQ, and both the total and the subdimensions demonstrated good reliability. The network analysis has further enriched these results, showing the central role of the items attributable to Emotional Dysregulation or Reflexivity in influencing the network as well as the contribution of aspects related to Relational Discomfort in managing the flow of communication flow. Such findings may have useful clinical implications and emphasize the usefulness of the MMQ in both research and clinical practice.

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.

Activity system, schizotypal personality, and mentalization: A study between halted activity and COVID-19 conducted in Henan, China

The pandemic-related lifestyle has potentially imposed crucial disturbances on daily and long-term activities, which, in turn, were associated with thought disturbance. This study investigates how the characteristics of the activity system during pandemic-related restrictions are associated with other psychomental aspects. By focusing on PTSD, mentalization, and schizotypal personality, and by inquiring about the main components of the activity system of 852 college students (Zhengzhou, Henan, China)- including the goals orienting their activity, goals' terms and types, the motivation levels and sources, the activity type and engagement time, the flow of the activity, and how due to pandemic lifestyle-results revealed that the activity system's components have significant associations with PTSD, reflective function, and schizotypal traits. Additionally, some of the activity system's elements have a significant predictive role regarding schizotypal traits. The study considered that the life narrative during the pandemic has been disturbed; hence, this may have a crucial effect on mind coherence. Additionally, the outcomes from the pandemic context will support mental health interventions in other similar contexts where the life narrative is severely affected.

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.

Promoting an integrating recovery style: A mentalization-informed approach

How a person recovers after a psychotic episode is known to be a key predictor of treatment response, impacting a person's sense of self and interpersonal relationships. An integrating recovery style, characterized by more curiosity about the psychotic episode and its potential meaning, has been shown to produce better outcomes. A novel therapeutic treatment, mentalization-based therapy for psychosis, targets the potential mechanisms (i.e., curiosity about mental states, affect modulation, and interpersonal awareness) that might foster an integrating recovery style, enabling a person to make meaning of their episode and use others to facilitate exploration. In this case study, we present the treatment of an emerging adult who sought residential treatment following her first psychotic episode and who initially presented with a guarded, dismissive approach to her symptoms and gradually formed a more integrating recovery style.

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.

Reflective Functioning in Patients with Irritable Bowel Syndrome, Non-Affective Psychosis and Affective Disorders-Differences and Similarities

Irritable bowel syndrome (IBS), as part of the functional somatic syndromes, is frequent in the general population. Medical care and morbidity costs are high, and so is the psychological and somatic strain. The etiopathogenesis of IBS is still poorly understood; it is assumed to be multifactorial and to include biopsychosocial factors. Links between the intestine, psyche, nervous system (e.g., via the hypothalamic-pituitary-adrenal axis (HPA-Axis/neurotransmitters) and with the microbiome, the immune system have lately been investigated. Factors such as personality traits, mentalization, and early attachment strategies (deactivating and hyperactivating) have been suggested to influence IBS with relevance for treatment regimens. At this time, data on reflective functioning (RF) is lacking. Within a cross-sectional, we examined the mentalizing capacity of a clinical sample (n = 90) consisting of patients with IBS (n = 30), affective disorders (AD; n = 28), and non-affective psychosis (NAP; n = 32). The reflective functioning scale was used based on the brief reflective function interview (BRFI). The results revealed severe impairment in patients with IBS concerning their mentalizing ability, which was comparable to patients with affective disorders. Patients with non-affective-psychosis showed the lowest mentalizing ability. Thus, psychotherapeutic treatment with a focus on mentalization could be a promising approach.

From Fragmentation to Coherence: Psychodynamic Psychotherapy for Psychosis through the Lens of Metacognition

Psychoanalysis has produced important theories that help explain the radical alterations in self-experience central for persons experiencing psychosis. These concepts have led to important clinical developments, case studies, and some research on the efficacy of psychodynamic psychotherapy for psychosis (Gottdiener, 2006). However, psychodynamic psychotherapy has struggled to produce operationalized constructs to measure how it enhances self-development and the therapeutic mechanisms of action that facilitate these changes. Outside of psychoanalysis, some researchers have focused on the construct of metacognition (i.e. thinking about thinking) and its relevance to understanding psychosis. Proponents of this paradigm have created an integrative, exploratory therapy (MERIT, Lysaker & Klion, 2017) that blends various therapeutic traditions that overlap with psychodynamic psychotherapy and mentalization (Ridenour, Knauss, & Hamm, 2019). In this paper, we will present a short-term intensive case study of psychodynamic psychotherapy with a young man experiencing psychosis in residential treatment and then analyze the therapy through the lens of metacognition to provide constructs that illustrate the ways that it promotes recovery and self-integration.

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

As research on metacognition has progressed a significant array of definitions, methodologies and therapeutic applications have emerged. Some of this work has primarily framed metacognition as an activity carried out by one person in order to know, monitor, and adjust their beliefs, memories, and behaviors. Accordingly, problems with metacognition have often been characterized as issues related to cognition. This, however, risks neglecting how metacognition is also a fundamentally intersubjective act, one in which human beings know and reflect upon themselves and others primarily with and through connections with other people. In this paper, we review research on metacognition in schizophrenia using the integrative model of metacognition and a research paradigm in which metacognition is assessed within personal narratives. Stimulated by this work, we discuss how disturbances in intersubjective experience and metacognitive capacity mutually influence one another, with disruptions in metacognition perhaps more deeply understood as disruptions in relatedness with others. We then discuss how metacognition and intersubjectivity each affect mental health. We finally focus on the implications of this for treatments that target metacognition as well as future directions for research.

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.

To chase or not to chase: A study on the role of mentalization and alcohol consumption in chasing behavior

BACKGROUND AND AIMS

Chasing is a behavioral marker and a diagnostic criterion for gambling disorder. Although chasing has been recognized to play a central role in gambling disorder, research on this topic is relatively scarce. This study investigated the association between chasing, alcohol consumption, and mentalization among habitual gamblers.

METHOD

A total of 132 adults took part in the study. Participants were administered the South Oaks Gambling Screen, the Alcohol Use Disorders Identification Test, the Reflective Functioning Questionnaire, and a laboratory task assessing chasing behavior. Participants were randomly assigned to three experimental conditions (Control, Loss, and Win). To deeply investigate chasing behavior, participants were requested to indicate the reasons for stopping or continuing playing at the end of the experimental session.

RESULTS

Logistic regression analysis showed that the choice to stop or continue playing depended on experimental condition and alcohol use. Hierarchical linear regression indicated that chasing propensity was affected by experimental condition, alcohol consumption, and deficit in mentalization. The results of path analysis showed that hypermentalizing predicts chasing not only directly, but also indirectly via alcohol consumption.

CONCLUSIONS

Overall, these results for the first time showed that hypermentalization plays a key role in chasing behavior over and above gambling severity. Since these findings support the idea that chasers and non-chasers are different subtypes of gamblers, clinical interventions should consider the additive role of chasing in gambling disorder.