Metacognitive Reflective and Insight Therapy for People in Early Phase of a Schizophrenia Spectrum Disorder

Schizophrenia often involves a loss of metacognitive capacity, the ability to form complex and integrated representations of self and others. Independent of symptoms and neurocognition, deficits in synthetic metacognition are related to difficulties of engaging in goal‐directed activities in social and vocational settings. Within this backdrop, we provide a case report of the effects of Metacognitive Reflective Insight Therapy (MERIT) that assisted a patient suffering from first episode schizophrenia during 2 years of individual psychotherapy. A total of 8 elements of MERIT that stimulate and promote metacognitive capacity are presented. As illustrated in this report, these procedures helped the patient move from a state in which he had virtually no complex ideas about himself or others to one in which he had developed integrated and realistic ideas about his own identity and the identity of others. He then could use these representations to understand and effectively respond to life challenges.     

The dialogical self in psychotherapy for persons with schizophrenia: a case study

Schizophrenia often involves a profound experience of one's identity as diminished, which complicates adaptation to the demands of daily life. Within a backdrop of dialogical self-theory, we provide a report of an individual psychotherapy over the course of 4 years that assisted a patient suffering from schizophrenia to move from a state in which few aspects of self were available for internal or external conversation to one in which there was greater accessibility of multiple aspects of self, leading to richer dialogues, improved function, and a better quality of life. It is suggested a primary intervention of the therapist was continuously to offer the client a view of himself that invited him to experience himself in a plausible manner shared with and listened to by another.     

Correlates of self‐harm behaviour in acutely ill patients with schizophrenia

Objective. This study compared acutely ill patients with schizophrenia with a history of self‐harm (N=17) to those without a history of self‐harm (N=16) on measures of depression, hopelessness, suicidal ideation, and demographic and psychiatric variables. A subgroup of these patients who experience auditory hallucinations, with and without a history of self‐harm, were selected and compared on measures of depression, hopelessness, suicidal ideation and beliefs about voices. Design. Employing a cross‐sectional design, in‐patients of two local psychiatric hospital, who met DSM‐IV‐TR criteria for schizophrenia and who were in an acute phase of the illness, were selected. Method. Each patient was assessed using the Beck Depressions Inventory (BDI), Beck Hopelessness Scale (BHS) and the Beck Suicide Scale (BSS). Patients who experienced auditory verbal hallucinations completed the Beliefs About Voices Questionnaire Revised (BAVQ‐R). Patients with a history of self‐harm completed the Beck Suicide Intent Scale (BSI). Results. Patients with a history of self‐harm (N=17) had significantly greater symptoms of depression, greater suicidal thoughts, increased number of hospital admissions, greater duration of illness and were more likely to be married, compared to patients without a history of self‐harm (N=16). Among the subgroup of patients who experience auditory hallucinations, those with a history of self‐harm (N=9), believed their voice to be more malevolent, had a tendency to resist their voice and experienced significantly greater symptoms of depression and hopelessness compared to those without a history of self‐harm (N=6). Conclusions. These findings highlight the importance for screening by clinicians during inpatient hospital stays and for monitoring to be ongoing following discharge. For the subgroup of patients who experience auditory hallucinations, future research should seek to explore the relationship between self‐harm and beliefs about voices.     

Integrative Psychotherapy for Schizophrenia: Its Potential for a Central Role in Recovery Oriented Treatment

Research has affirmed that recovery from serious mental illnesses (SMI), such as schizophrenia, is a common outcome and often involves subjective changes in the experience of self, one's identity, and one's sense of agency in the world. Although many different interventions have been developed and validated, efforts to consider how those interventions should be integrated to assist people to direct their own recovery have been limited. This article considers the 5 case reports of psychotherapy presented in this special issue that have sought to integrate scientifically valid approaches within a recovery frame work. Exploring shared themes, this article suggests that a common set of processes exists between these examples of integrative work. These include therapist acceptance of a vulnerable stance in the face of uncertainty, which rejects stigma and remains open to knowing the person. This ultimately allows the kinds of meaning to be made jointly between the therapist and client that promote recovery.     

A metacognitive model of the sense of agency over thoughts

Introduction. The sense of agency over thoughts is the experience of oneself qua agent of mental action. Those suffering certain psychotic symptoms are thought to have a deficient sense of agency. Here I seek to explain this sense of agency in terms of metacognition.

Method. I start with the proposal that the sense of agency is elicited by metacognitive monitoring representations that are used in the intentional inhibition of thoughts. I apply this model to verbal hallucinations and the like and examine the plausibility of this model explaining deficits associated with these symptoms.

Results. By tying the sense of agency to metacognitive inhibition I propose that the loss of a sense of agency in certain psychotic symptoms is accompanied by a particular deficit in the patient's ability to control their own thinking. This is consistent with the experiences of those at high risk of developing hallucinations, who report more intrusive thoughts than controls. The model I present is able to explain why those at risk of developing verbal hallucinations and those suffering from verbal hallucinations have deficits in the intentional inhibition of thought. I defend this account from a possible objection by distinguishing the form of the intentional inhibition deficit displayed by those suffering verbal hallucination from that displayed by those suffering from orbital-frontal cortex lesions and posttraumatic stress disorder.

Conclusion. A plausible hypothesis is that the sense of agency over thoughts is elicited by the metacognitive monitoring representation used to intentionally inhibit thoughts. The deficit in the sense of agency over thoughts associated with certain psychotic symptoms could be explained by a failure to properly metacognitively monitor certain thought processes.     

Psychotherapy and schizophrenia: An analysis of requirements of individual psychotherapy with persons who experience manifestly barren or empty selves

Emerging views of schizophrenia emphasize that part of recovery involves persons reclaiming a sense of their own identity, agency and personal worth. While this intuitively seems a matter where psychotherapy might be uniquely useful, it raises the issue of how this should be facilitated particularly among persons who experience themselves as unable to engage in dialogue with others. In this article, we explore how integrative psychotherapy might address issues of self‐narrative and recovery from schizophrenia among persons experiencing, in particular profound levels of emptiness or barrenness. Illustrated with two case examples, we explore barriers posed to psychotherapy by clients' minimalist self‐presentations and describe three stages for integrative interventions that can revitalize dialogues within the client and between the client and others, ultimately enabling the reconstruction of a client's personal narrative within which a life plan might be articulated, guiding future action.     

New life for schizophrenia psychotherapy in the light of phenomenology

Recent contributions to the theoretical conception and empirical evaluation of schizophrenia in the light of phenomenology are opening the way to new perspectives in psychotherapy. The phenomenological conception understands schizophrenia as a disturbance of the basic sense of selfhood (ipseity) characterized by hyper‐reflexivity and diminished sense of self. Evaluation consists of examining the anomalous self‐experience in a series of domains, which makes the conception presented operable. On this basis, a phenomenologically informed psychotherapy is introduced. Its characteristics are pointed out and early intervention is reviewed (the last frontier in psychosis) from this perspective. Finally, a series of psychotherapies which, although they do not have a phenomenological origin, may be seen from that perspective, are re‐examined. These are the narrative, mindfulness and acceptance and commitment therapies. Copyright © 2010 John Wiley & Sons, Ltd. Key Practitioner Messages: ? The phenomenological conception can contribute to a new understanding of schizophrenia. ? The phenomenological conception can contribute to evaluation of the subjective experience. ? The phenomenological conception opens a new perspective for psychotherapy of schizophrenia.     

An Integrative Psychotherapy Approach to Foster Community Engagement and Rehabilitation in Schizophrenia: A Case Study Illustration

This case study illustrates the use of a long‐term integrative psychotherapy approach with a middle‐ aged man with chronic schizophrenia and a mood disorder. The case of “Holst” describes a man with a history of insecure attachment and trauma who later went on to contract a serious chronic illness, precipitating the onset of psychotic symptoms, depression, and chronic suicidal ideation, resulting in multiple hospitalizations. Combining metacognition‐oriented therapy with elements of cognitive behavioral therapy and psychiatric rehabilitation, this approach fostered significantly improved community functioning and attainment of personal goals over time. Through the journey of therapy, the patient also developed a more coherent narrative about his life, established a stable sense of self, and became an active agent in the world. This case illustration demonstrates that these three different approaches can be used in a sequential and complementary fashion to foster recovery in the midst of serious physical and mental illness.     

Self‐stigma and the mediating impact of the “why try” effect on depression

The “why try” effect, a consequence of self‐stigma, is a sense of behavioral futility that may worsen depression. This study examines the regressive model of self‐stigma, the factor structure of a why try measure, and the pathway through which self‐stigma leads to depression. Data from 291 people self‐identifying with mental illness were collected through an online survey. Participants completed the Why Try Stigma Scale (WTSS) and measures of self‐stigma and depression. Structural equation modeling was used to test the WTSS factor structure and path models. Reducing the WTSS from 12 to 6 items led to good fit. The regressive model of self‐stigma was validated. A good fit was demonstrated for a model in which harm leads to unworthiness, then incapability, and then depression. The regressive model worsens sense of worthiness, which in turn affects personal capability, resulting in increased depression.     

The role of attributions in the process of overcoming shame: A qualitative analysis

Objectives While attributions have been found to play an important role in the experience of shame, little is currently known about attributions that occur as part of shame reparation. This exploratory study investigated the attributions associated with recovery from shame, based on the perspectives of participants. Design Grounded theory was used in data collection and analysis. This approach has been used extensively for developing understandings of how people construct meaning, interpret events, and act on the basis of their beliefs and interpretations. Methods The participants were nine women and four men between the ages of 24 and 70. Data came from interviews in which the participants recalled a distressing shame experience and described how they recovered. Emphasis was on the participants' subjective perspectives, meanings, and interpretations. Results Shame involved global and stable dispositional attributions where the entire self was regarded as flawed and unattractive, and participants perceived themselves as powerless to change an unwanted identity. Internal causal attributions and self‐blame were present in most but not all shame experiences. Recovery involved a movement towards specific and unstable attributions that enhanced self‐concept and maximized a sense of power and control over the future. Shared and external factors that contributed to the event were also identified. Conclusions When applied to psychotherapy for shame‐related distress, these findings point to the importance of exploring clients' attributions related to specific shame events and using interventions that promote attributional change. Directions for further research are discussed.     

Are shame and self‐criticism the path to the pervasive effect of social stress reactivity on social functioning in psychosis?

It is widely known that stress reactivity and social functioning impairment are important difficulties in people with psychosis. However, the specific impact of stress reactivity on social functioning and its underlying mechanisms are still less explored. Social rank variables, such as shame and self‐criticism, have been pointed out as relevant in the development, maintenance of several types of psychosocial suffering and, specifically, in psychotic disorders. This study's aim was to explore the associations between external shame, self‐criticism, social stress reactivity, and social functioning difficulties and understand the mediator role of shame and self‐criticism in the relationship between social stress reactivity and social functioning. Seventy‐seven participants with a psychotic disorder filled in self‐reported measures of stress reactivity, shame, and self‐criticism and were clinically evaluated for social functioning. To study the associations between variables in the study, Spearman correlation coefficients were used. The PROCESS macro was used to test the sequential mediation analyses. All variables under study were associated with each other, and social stress reactivity predicted social functioning difficulties through external shame, whereas self‐criticism was not a significant mediator. The present study highlights the role of external shame in the pathway from stress reactivity to social impairment. These results inform recovery‐oriented interventions and reinforce the relevance of considering social competitive mentality when working with people with psychosis. Further research is needed to clarify the role of self‐to‐self relationship in social impairment and to identify other mechanisms aimed at dealing with shame used by people with psychosis.     

The Role of Interpersonal Connection,Personal Narrative,and Metacognition in Integrative Psychotherapy for Schizophrenia: A Case Report

The recovery movement has not only challenged traditional pessimism regarding schizophrenia but also presented opportunities for the possibilities for psychotherapy for people with the disorder. Though in the past psychotherapy models were often pitted against one another, recently there have been emergent reports of a range of integrative models sharing an emphasis on recovery and a number of conceptual elements. These shared elements include attention to the importance of interpersonal processes, personal narrative, and metacognition, with interest in their role in not only the disorder but also the processes by which people pursue recovery. This article explores one application of this framework in the psychotherapy of a woman with prolonged experience of schizophrenia and significant functional impairments.     

Shared decision making in the recovery of people with schizophrenia: The role of metacognitive capacities in insight and pragmatic language use

In the development of consumer-centered care for mental health consumers with schizophrenia, one key ingredient is consumer participation in health care decisions together with their healthcare providers, termed "shared decision making" (SDM). SDM requires consumers to form a number of complex ideas about themselves and their providers then use that knowledge to make sense of the illness and reach medical and psychosocial decisions. However, metacognitive deficits widely observed in schizophrenia might lead to poor insight and pragmatic language deficits in some consumers, disrupting the whole process by which a personal and consensually valid narrative account of psychiatric challenges is synthesized and flexibly evolved. Given the current understanding that it is possible to improve metacognition, in this article we summarize how Metacognitive Training (MCT) and individual psychotherapy could potentially be tailored, or modified, to help consumers to develop metacognitive capacities with an end goal of facilitating the SDM process. Consistent with the principles of consumer-defined recovery, we also suggest a strategy for engaging consumers in SDM dialogue based on "where the consumers are at". Providers are advised to be cognizant of their medically driven perspective and attempt to work with the consumers in the perspective of the consumers' own recovery goals.     

Automatic processing of facial emotion in schizophrenia with and without affective negative symptoms

Introduction. It is assumed that people spontaneously evaluate any incoming stimulus as pleasant or unpleasant. The evaluative response appears to structure perception and to have direct links to emotional states.Methods. To investigate the automatic processing of face valence a sequential priming task based on emotional face stimuli was administered to schizophrenia patients with a flat affect expression, schizophrenia patients suffering from anhedonia, schizophrenia patients not suffering from anhedonia or flat affect, and healthy controls. The Scale for the Assessment of Negative Symptoms (Andreasen, 1989) was applied to evaluate affective symptoms and categorise patients into groups.Results. Schizophrenia patients without affective negative symptoms exhibited reversed priming effects similar to that of healthy subjects. In contrast, flat affect patients and anhedonic patients showed only a prime effect due to negative facial valence. In the flat affect patient group, negative prime faces facilitated the evaluation of target faces, whereas in the anhedonic patient group negative prime faces tended to inhibit the evaluation of subsequent target faces.Conclusions. The present findings support the idea that chronic schizophrenia patients extract automatically the valence of emotional facial expression but they also suggest processing differences between schizophrenia patients as a function of affective symptoms.     

DEVELOPMENT OF A THREE‐FACTOR PSYCHOLOGICAL SENSE OF COMMUNITY SCALE

A variety of sense of community measures have been developed, but the identification of latent factors in developed scales to measure this construct has encountered significant psychometric problems involving reliability and validity. We present a new measure called the Psychological Sense of Community Scale, which is based on three distinct ecological domains involving the individual, microsystem, and macrosystem. We used an exploratory factor analysis to investigate our three theoretical domains involving Self (identity and importance to self), Membership (social relationships), and Entity (a group's organization and purpose). Three theoretically derived factors emerged with good measurement model fit, internal reliabilities, and convergent validity. Our study also found multiplicative over additive effects, suggesting each of the three domains is necessary to understand the experience of sense of community. This scale can be adapted to a variety of contexts and situations in future research.     

Explaining depression symptoms in patients with social anxiety disorder: Do maladaptive metacognitive beliefs play a role?

Social anxiety disorder (SAD) is a major risk factor for developing symptoms of depression. Severity of social anxiety has previously been identified as a risk factor, and cognitive models emphasize dysfunctional schemas and self‐processing as the key vulnerability factors underlying general distress in SAD. However, in the metacognitive model, depressive and other symptoms are related to metacognitive beliefs. The aim of this study was therefore to test the relative contribution of metacognitions when controlling for SAD severity and factors postulated in cognitive models. In a cross‐sectional design, 102 patients diagnosed with primary SAD were included. We found that negative metacognitive beliefs concerning uncontrollability and danger and low confidence in memory emerged as the only factors explaining depressive symptoms in the regression model, suggesting that metacognitive beliefs are associated with increased depressive symptoms in SAD patients.     

Metacognition and persecutory delusions: tests of a metacognitive model in a clinical population and comparisons with non-patients

BACKGROUND. A metacognitive approach to the conceptualization of paranoia as a strategy for managing interpersonal threat has gained some support in studies of non-clinical populations. This study reports a clinical validation of the Beliefs about Paranoia Scale (BaPS), a self-report measure to assess metacognitive beliefs about paranoia. We aimed to replicate the factor structure of a brief version of the measure and test the specific hypotheses that positive beliefs about paranoia would predict levels of suspiciousness, and that negative beliefs about paranoia would predict problematic persecutory delusions. METHOD. A total of 122 patients meeting criteria for a diagnosis of a schizophrenia spectrum disorder completed the questionnaire assessing beliefs about paranoia. In addition, 61 of the participants were administered the Structured Clinical Interview for DSM-IV, and 60 were administered the Positive and Negative Syndromes of Schizophrenia Scale. One hundred and seventy-eight non-patients were also recruited (an undergraduate sample). RESULTS. Principal components factor analysis showed that the three-factor solution was replicated (comprising negative beliefs about paranoia, paranoia as a survival strategy, and normalizing beliefs). This measure showed good internal consistency (alphas ranged from .85 to .91). Correlational analyses revealed that positive beliefs about paranoia were positively associated with levels of suspiciousness, and independent t tests showed that negative beliefs about paranoia were significantly higher in patients with a diagnosis of schizophrenia meeting criteria for persecutory delusions in comparison to those without. Analyses of covariance showed that patients scored higher than non-patients on both positive and negative beliefs, but logistic regression did not demonstrate that co-occurrence of these beliefs predicted patient status. CONCLUSIONS. Three of our four hypotheses were confirmed, suggesting that a metacognitive approach to the conceptualization of paranoia as a strategy for managing interpersonal threat may have some utility for understanding clinical paranoia. Such a model is described and the clinical implications of the findings are also discussed.     

Information versus experience: a comparison of an information leaflet on antidepressants with lay experience of treatment

The quality of patient information leaflets has been criticised for being too medico centred. Written information produced by a patient organisation should be tailored to members' expressed needs, and based on their experience and therefore useful in helping patients to self-manage their condition. Views expressed in semi-structured interviews with 30 members of a self help group for depression were compared with the content of an antidepressant leaflet produced by the parent organisation. The information leaflet used six frequently asked questions to deliver a biomedical discourse on antidepressants. Members of the group had questions not included in the leaflet around self help, stigma and sense of self, and more complex answers to the six questions. It cannot be assumed that information leaflets written by lay led organisations are patient centred and promote self help. To assist in facilitating concordance between patient and prescriber medicine information leaflets should draw on patient experience of the condition and treatment for it.