Addressing metacognitive capacity for self reflection in the psychotherapy for schizophrenia: A conceptual model of the key tasks and processes

Purpose.?Recognition that recovery from schizophrenia may involve a deepening of the experience of being in the world has led to the possibility that psychotherapy may play a key role in treatment by enhancing metacognition, or the capacity to think about thinking. While the potential of psychotherapy to enhance metacognition in non-psychotic disorders has been discussed in depth, little has been written about how psychotherapy may systematically address metacognition in schizophrenia. Accordingly, the current paper formulates a model of how psychotherapy might address one specific element of metacognition, namely self-reflectivity. Methods.?Procedures are outlined for assessing clients' capacity for self-reflectivity within narrative contexts during psychotherapy. Results.?Targeted interventions are identified which are tailored to clients' capacities in the moment and which assist clients to think about their own thinking at the level of which they are capable. This may lead clients over time to develop a greater ability to engage in acts of increasingly complex self-reflectivity. Conclusions.?Individual psychotherapy can be modified and utilized to assist persons with schizophrenia to move towards recovery by assisting them to develop the capacity for self-reflectivity. This may lead to clients having a fuller experience of themselves as a being in the world with a richer and more coherent personal narrative.     

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.     

Narrative transformation as an outcome in the psychotherapy of schizophrenia

Assertions that changes or transformations in narratives contribute significantly to recovery from schizophrenia persist as a cornerstone of some psychotherapies. Yet when narrative transformation occurs in schizophrenia, what is there about the client's story that tangibly changes, and how might that be measured? To address this issue, we review literature on the importance of narrative transformation and identify narrative qualities that might theoretically change. We then report content and thematic analyses of the qualities of narratives that might potentially change over 14 months of psychotherapy. These analyses suggest that narratives in schizophrenia may gain complexity and dynamism, but the changes do not entail the creation of a new story or the ‘awakening’ of an ‘old’ self. From these analyses, the hypothesis that narrative transformation may occur in terms of growth in the richness of the internal dialogue that produces narrative is posed for future research.     

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.     

Witnessing Clients’ Emotional Transformation: An Emotion‐Focused Therapist's Experience of Providing Therapy

Emotion‐focused therapy (EFT) is an integrative–humanistic, research‐informed, psychological intervention characterized by sustained focus on the client's emotional pain and its transformation. This article discusses the impacts on the therapist when encountering and transforming the client's vulnerability. It is organized around the different phases of the therapy process: meeting a new client, accessing the client's core emotional pain, transforming the client's emotional pain, and ending the therapeutic work. The article also contains personal experiences of the author and provides illustrations of impactful events from therapy sessions. The work, it is suggested, provides significant learning for the therapist on both a personal and a professional level, leading, for example, to the therapist's maturation, better connection with personal hurts and vulnerabilities, greater courage in regard to sharing such feelings, greater kindness toward others and the self, and greater determination to be braver when facing adversity or injustice.     

Narrative research in psychotherapy: A critical review

Purpose . This paper is a review of studies which utilise the notion of narrative to analyse psychotherapy. Its purpose is to systematically present this diverse field of research, to highlight common themes and divergences between different strands and to further the development and integration of narrative research in psychotherapy. Methods . The paper reviews studies which employ an applied textual analysis of narratives produced in the context of psychotherapy. Criteria for inclusion of studies are, firstly, the analysis of therapeutic and therapy‐related texts and, secondly, the adoption of a narrative psychological perspective. The studies were examined on the basis of the notion of narrative they employ and the aspects of client narratives they focus on, and were grouped accordingly in the review. Results . The majority of the studies reviewed assume a constructivist approach to narrative, adopt a representational view of language, focus primarily on client micro‐narratives and relate to cognitive‐constructivist and process‐experiential psychotherapeutic approaches. A smaller group of studies assume a social constructionist approach to narrative and a functional view of language, focus on micro‐narratives, highlight the interactional and wider social aspects of narrative and relate to postmodern trends in psychotherapy. Conclusions . The range of conceptualisations of narrative in the studies reviewed, from a representational psychological view to a constructionist social view, reflects tensions within narrative psychology itself. Moreover, two trends can be discerned in the field reviewed, narrative analysis of therapy, which draws from narrative theory and utilises the analytic approaches of narrative research to study psychotherapy, and analyses of narrative in therapy, which study client narratives using non‐narrative qualitative methods. Finally, the paper highlights the need for integration of this diverse field of research and urges for the development of narrative studies of psychotherapy which employ a broader social understanding of narrative production and transformation.     

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.     

Exploring identity and personal meanings in psychosis using the repertory grid technique: A systematic review

Current research and clinical practice in person‐centred approaches highlight the importance of self, identity, and personal meanings in psychosis. Previous research has focused on dimensions of self, but less attention has been paid to the personal meanings involved in identity. The personal construct theory framework and the repertory grid technique (RGT) allow the study of identity and personal meanings within person‐centred approaches of psychopathology and treatment in psychosis, as suggested by studies that began more than 40 years ago. However, their contributions have not yet been reviewed. We aimed to systematically review the evidence for the role of identity and personal meanings in psychotic disorders. We performed a systematic search using personal construct and RGT terms in PsycINFO, Web of Science, PubMed, EBSCO, Scopus, and Google Scholar. After identifying 2,574 articles, 15 were included. Nine studies followed an idiographic assessment, and six were nomothetic. Patients reported their subjective experience of isolation in terms of high self‐ideal discrepancy and high perceived discrepancy with their significant others, which some studies associated with a lower degree of recovery or with the way in which positive symptoms were construed. Self‐fragmentation either decreased with interventions or was associated with recovery. Evidence regarding interpersonal construing was less consistent, but there was a tendency for patients to show a more rigid cognitive structure than controls. To conclude, we found some evidence that self‐discrepancies, fragmentation of self, and interpersonal construing are affected in psychosis and potentially modifiable through psychotherapy.     

Dimensional measure of self and interpersonal functioning: Comparisons with treatment alliance and readiness for inpatient psychotherapy

The social cognition and object relations scale‐global rating method is a clinical rating system assessing 8 domains of self and interpersonal functioning. It can be applied to score numerous forms of narrative data. In this study, we investigate the SCORS‐G relationship to measures of alliance and readiness for psychotherapy with an adolescent inpatient sample. Seventy‐two psychiatrically hospitalized adolescents were consented and subsequently rated by their individual and group therapist using the SCORS‐G. The unit psychiatrist also completed an assessment of patients' readiness for inpatient psychotherapy. The patients completed a self‐report of their alliance with the inpatient treatment team as a whole. SCORS‐G ratings were positively correlated with assessments of readiness for inpatient psychotherapy and patient‐reported alliance. This study further demonstrates the clinical utility of the SCORS‐G with adolescents.     

‘You Can Take it With You’: Transitions and Transitional Objects in Psychotherapy with Children Who have Learning Disabilities

This paper will consider what impact a learning disability may have on development and transition in a child's life. With reference to Hollins and Sinason's ‘Three secrets’ (2000), Alvarez's ‘Levels of psychoanalytic work’ (2012), and attachment theory, I will reflect on the development of the self when there is learning disability. The paper will go on to relate Winnicott's paper, ‘Transitional objects and transitional phenomena’ (1953) to the theory and practice of integrative arts child psychotherapy (IACP). In IACP, objects, play and creativity form a central part of the treatment. Drawing on clinical material from my long‐term treatment of two young people in particular, I will link the therapeutic effect of objects with Winnicott's ideas about creativity, aggression, motivation and the expression of self. In the paper I set out how, through the therapeutic use of objects and what I call, ‘object games’ we were able to address the children's experiences of trauma as well as the impact of their disabilities. I will describe the changes I saw in the internal worlds of my patients which in turn led to significant and positive changes in their relationships with self and with others. These changes came, over time, to allow them greater independence and self‐determination in everyday life.     

Case Formulation and the Therapeutic Relationship: The Role of Therapist Self‐Reflection and Self‐Revelation

This article examines the role of the therapist's self‐reflection and self‐revelation in case formulation. We believe that a collaboratively constructed case formulation must always be considered in the context of an evolving therapeutic relationship. Further, self‐reflection and self‐revelation on the part of the therapist are critical for a more elaborate and nuanced case formulation and for understanding the patient. This highlights the importance of attunement to the here and now and the evolving therapeutic relationship. From this attunement, the therapist's self‐reflection and self‐revelation can emerge further, which can lead to the patient's personal growth and increased self–other awareness. To illustrate our point, we present an integrative, relational model in the case of a patient who has been in treatment.     

Examining the relationship between object relations and interpersonal distress in a clinical sample

The goal of the present study was to explore the relationship between patients' object relational functioning (Social Cognition and Object Relations Scale‐Global Ratings) as rated by clinicians during the course of outpatient psychodynamic psychotherapy in a university‐based clinic and patient self‐reported interpersonal vulnerabilities (Inventory of Interpersonal Problems‐64). Participants (n = 112) were outpatients entering treatment at a university‐based psychotherapy clinic and were diagnosed primarily with mood disorders as well as Axis II relational problems and features. Participants completed the IIP‐64 prior to receiving therapy, and SCORS‐G ratings were based on patients' level of relational functioning during the evaluation process (i.e., the semistructured interview, follow‐up and feedback) and across the first two psychotherapy sessions. Results showed a significant relationship between the IIP‐64 Total score with SCORS‐GSelf‐Esteem (r = ?.21, p < .05) and Affective Quality of Representations (r = ?.20, p < .05), wherein self‐reported interpersonal dysfunction was greater among patients who had lower self‐worth and perceived others as more malevolent. These findings suggest that patients who rated themselves as having more significant interpersonal difficulty reported more negative expectations and experiences of relationships in their psychotherapy narratives. The utility of the SCORS‐G and the IIP‐64 as two different avenues of assessing patient relational functioning is explored.     

Responsiveness in Psychotherapy

Human interaction, including psychotherapy, is systematically responsive; therapists' and clients' behavior is influenced by emerging context, including perceptions of each other's characteristics and behavior. Feedback and mutual influence occur on a wide range of time scales, including treatment assignment, strategy, and tactics, -and even within the delivery of interventions. Consequently, research that assumes linear relations among psychotherapeutic variables may not be trustworthy. The concept of responsiveness helps show how client characteristics, therapist characteristics, and process components may be important in psychotherapy despite a lack of linear relations to outcomes. Research strategies that incorporate responsiveness include the use of evaluative measures, systems approaches, and qualitative and narrative approaches.     

A model of narrative development: Implications for understanding psychopathology and guiding therapy

Story‐telling is one of the psyche's basic functions. All of us organize our experience in the form of narratives in order to give meaning to events, make forecasts about how situations will evolve, guide our actions in relationships and make our self‐experience coherent. Here we present a theoretical model which starts out from the hypothesis that, when they are created, the narratives we continuously relate to ourselves and others do not have a pre‐existing form. We propose a model for understanding the way each organizational level is formed in the mind, and works and interacts with other levels; and what psychological disorders could affect it, ranging from the basic, where there are simple aggregates of mental images, to the more complex, where there are true and proper stories, in which the characters of the internal scenario interact with each other. According to our model, it is possible to hypothesize the existence of:

• 1 a pre‐narrative level, and
• 2 a proto‐narrative level, followed by three extended narrative levels:
• 3 a procedural unconscious narrative level
• 4 a conscious propositional narrative level, and
• 5 a verbal interactive narrative level.

Our hypothesis is based on:

• 1 a review of various theories from different fields of research; and
• 2 illustrative clinical material obtained by recording psychotherapy sessions with severely personality‐disordered patients.

     

Clients' reasons for terminating psychotherapy: A quantitative and qualitative inquiry

Objective. To study private‐practice clients' perspective on reasons for psychotherapy termination and how these are related to demographic and treatment variables and to satisfaction with therapy. Design. Eighty‐four persons who had been in extended private‐practice psychotherapy which ended in the preceding three years participated in the study. Mean number of months in treatment was 27.70 (SD =18.70). Method. Assessment included rating scales and open‐ended questions assessing demographic variables, reasons for terminating therapy, and satisfaction with therapy. Results. Quantitative results revealed that the most frequent reasons for termination were accomplishment of goals, circumstantial constraints and dissatisfaction with therapy, and that client satisfaction was positively related to positive reasons for termination. Qualitative results revealed two additional frequently mentioned reasons for termination: the client's need for independence and the client's involvement in new meaningful relationships. Conclusions. Findings suggest that psychotherapy termination may at times be required to facilitate the pursuit of personally meaningful goals.     

Losing the Internal Oedipal Mother and Loss of Sexual Desire

This paper aims to examine how it might be possible to use psychoanalytic concepts to explore a deeper understanding of the difficulties with conscious and unconscious same gender sexual desires in psychoanalytic psychotherapy. The author explores how the loss of the unconscious oedipal mother can be manifested as a loss of sexual desire in a couple's relationship. The author suggests that the move from what is referred to as the longed‐for state of being in perfect harmony, to a more realistic state of imperfect harmony can bring about the recovery of an unconscious belief that one can possess the oedipal mother. The move from this fantasy state of merger to a more reality‐based relationship can induce feelings of abandonment and loss, particularly of sexual desire. The implications of this for the transference and countertransference, and the conscious and unconscious nature of erotic desires within the therapeutic relationship are considered. The importance of aspects of technique and the need for non‐pathologizing use of concepts to help clinicians more fully explore formulations and therapeutic interventions are examined. While this paper focuses on lesbian relationships, the relevance of the ideas presented here for other gender pairings is explored.     

Mentalization‐based psychodynamic psychotherapy for psychosis

This article discusses and illustrates the use of mentalization‐based psychodynamic psychotherapy for disturbances of awareness of the self and others in patients with psychotic‐spectrum disorders. The literature on impairments of mental processes involved in self‐awareness and awareness of others occurring in psychotic illnesses and the relationship between childhood trauma and the emergence of psychotic symptoms is reviewed. A case illustrates how mentalization‐based treatment can facilitate treatment engagement and be used to manage enactments in the psychotherapy with a patient with a psychotic disorder. Mentalization‐based psychotherapy may offer a useful adjunct to antipsychotic medication and psychosocial evidence‐based treatments in the care of individuals in the early phase of psychotic disorders. © 2009 Wiley Periodicals, Inc. J Clin Psychol: In Session 65:1–12, 2009.