Sunita George

Targeting Insight in First Episode Psychosis: A Case Study of Metacognitive Reflection Insight Therapy (MERIT)

One aspect of schizophrenia contributing to its complexity is the lack of insight individuals often have into their illness. While poor insight is prevalent throughout the course of the illness, more severe levels are associated with first-episode psychosis (FEP). Interventions addressing insight are necessary but current treatments have been shown to have limited effectiveness. Thus, a novel intervention, Metacognitive Reflection and Insight Therapy (MERIT), is being studied for its efficacy of improving insight in individuals with schizophrenia spectrum disorders. MERIT is an integrative metacognitive therapy consisting of eight elements to assist clients in improving their ability to form complex ideas about themselves and others and to use this knowledge to respond to psychological problems. The present study is a case illustration of the implementation of MERIT to improve insight in FEP. Clinical outcomes were assessed and results showed that the client improved in both metacognition and insight. With replication, these results suggest that integrative metacognitive psychotherapy may serve as an intervention that improves insight in FEP, which marks an important step toward improved interventions for individuals with psychosis.

An integrative model of the impairments in insight in schizophrenia: emerging research on causal factors and treatments

ABSTRACT 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.

Contrasting metacognitive, social cognitive and alexithymia profiles in adults with borderline personality disorder, schizophrenia and substance use disorder

Deficits in the ability to recognize and think about mental states are broadly understood to be a root cause of dysfunction in Borderline Personality Disorder (PD). This study compared the magnitude of those deficits relative to other forms of serious mental illness or psychiatric conditions. Assessments were performed using the metacognition assessment scale-abbreviated (MAS-A), emotion recognition using the Bell Lysaker Emotion Recognition Test and alexithymia using the Toronto Alexithymia Scale among adults with schizophrenia (n = 65), Borderline PD (n = 34) and Substance Use disorder without psychosis or significant Borderline traits (n = 32). ANCOVA controlling for age revealed the Borderline PD group had significantly greater levels of metacognitive capacity on the MAS-A than the schizophrenia group and significantly lower levels of metacognitive capacity than the Substance Use group. Multiple comparisons revealed the Borderline PD group had significantly higher self-reflectivity and awareness of the others mind than the schizophrenia group but lesser mastery and decentration on the MAS-A than substance use group, after controlling for self-report of psychopathology and overall number of PD traits. The Borderline PD and Schizophrenia group had significantly higher levels of alexithymia than the substance use group. No differences were found for emotion recognition. Results suggest metacognitive functioning is differentially affected in different mental disorders.

Metacognitive Reflective and Insight Therapy for a Person Who Gained Maximal Levels of Metacognitive Capacity and Was Able to Terminate Therapy

Schizophrenia often involves a loss of metacognitive capacity, or the ability to form a complex and integrated sense of self and others. Independent of symptoms and impairments in neurocognition, metacognitive deficits are a barrier to the formation and sustenance of goal-directed activities of daily life and ultimately to recovery. Metacognitive reflective and insight therapy (MERIT) is a form of psychotherapy intended to assist patients to recover metacognitive capacity through intensive individual therapy. This paper presents a case illustration of how MERIT assisted a patient with prolonged schizophrenia and significant metacognitive deficits to develop a robustly complex understanding of himself and others and then to use that knowledge to agentically monitor his own experiences and effectively respond to life challenges. The eight elements of MERIT that stimulate and promote metacognitive capacity are presented with an emphasis on how they were implemented when the patient had reached some of the higher levels of metacognitive function.

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.

Cluster B Personality Disorder Traits as a Predictor of Therapeutic Alliance Over Time in Residential Treatment for Substance Use Disorders.

Abstract While poor therapeutic alliance is a robust predictor of poor outcome in substance abuse treatment, less is known about the barriers to therapeutic alliances in this group. To explore this issue, this study examined whether the severity of cluster B personality disorders predicted therapeutic alliances concurrently and prospectively in a residential substance treatment program for homeless veterans. Participants were 48 adults with a substance abuse disorder. Personality disorder traits were assessed using the Structured Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Personality Disorders, whereas therapeutic alliance was assessed at baseline using the Working Alliance Inventory. Partial correlations controlling for overall symptom severity measured with the Symptom Checklist 90 and education, revealed cluster B traits at baseline predicted all 4 assessments of therapeutic alliance even after controlling for initial levels of therapeutic alliance. Results suggest that higher levels of cluster B traits are a barrier to the formation of working alliances in residential substance treatment.

The Role of Metacognitive Self-Reflectivity in Emotional Awareness and Subjective Indices of Recovery in Schizophrenia.

Abstract Emotional awareness deficits in people with schizophrenia have been linked to poorer objective outcomes, but no work has investigated the relationship between emotional awareness and subjective recovery indices or metacognitive self-reflectivity. The authors hypothesized that increased emotional awareness would be associated with greater self-esteem, hope, and self-reflectivity and that self-reflectivity would moderate links between emotional awareness and self-esteem and hope—such that significant relationships would only be observed at lower levels of self-reflectivity. Participants were 56 people with schizophrenia spectrum disorders. Correlations revealed that better emotional awareness was significantly associated with increased self-esteem and hope but not self-reflectivity. Self-reflectivity moderated the relationship between emotional awareness and self-esteem but not hope. Overall, findings suggest that emotional awareness may affect self-esteem for those low in self-reflectivity, but other factors may be important for those with greater self-reflectivity. Results emphasize the importance of interventions tailored to enhance self-reflective capacity in clients with schizophrenia.

Negative symptoms and therapeutic connection: A qualitative analysis in a single case study with a patient with first episode psychosis.

Therapeutic connections with patients with negative symptoms of schizophrenia are often frail and tenuous, and perhaps even more so in first episode psychosis (FEP) due to a variety of factors. These factors include poor insight that is often more severely impaired in FEP, issues of identity as one faces serious mental illness in young adulthood, and confusion regarding the emergence of such symptoms in psychotherapy. Thus, forming and sustaining therapeutic connections with individuals with FEP poses unique challenges for therapists as they consider how to approach and understand negative symptoms that impact interpersonal connection within the context of building a therapeutic relationship. To explore this issue, we used qualitative methodology to identify content, therapist, and process factors that appeared to prompt negative symptoms and subsequently the collapse of the therapeutic connection with a patient experiencing FEP. The case examined was that of a 6-month psychotherapy that was part of a pilot study examining the use of metacognitive reflection and insight therapy (MERIT) in FEP. We identified four prominent codes across 24 psychotherapy transcripts that seemed to elicit negative symptoms and disrupt the therapeutic connection: therapeutic relationship, therapist challenges, therapist supports, and therapist notices. We propose that the emergence of negative symptoms in session are not simply a consequence of psychopathology, but instead appear to be a response to interpersonal dynamics occurring between the therapist and patient. This may require openness by the therapist to attend to and consider potential meaning behind these negative symptoms that emerge in session. Síntomas negativos y conexión terapéutica: un análisis cualitativo en único estudio de caso con un paciente con primer episodio de psicosis Las conexiones terapéuticas con pacientes con síntomas negativos de esquizofrenia a menudo son frágiles y tenues, y tal vez incluso más en el primer episodio de psicosis (FEP por sus iniciales en inglés) debido a una variedad de factores. Estos factores incluyen una percepción deficiente que a menudo se ve perjudicada más severamente en FEP, problemas de identidad ya que uno enfrenta una enfermedad mental grave en la edad adulta joven, y confusión con respecto a la aparición de tales síntomas en la psicoterapia. Por lo tanto, la formación y el mantenimiento de conexiones terapéuticas con personas con FEP plantean desafíos únicos para los terapeutas, ya que consideran cómo abordar y comprender los síntomas negativos que afectan la conexión interpersonal en el contexto de la construcción de una relación terapéutica. Para explorar este tema, utilizamos la metodología cualitativa para identificar el contenido, el terapeuta y los factores del proceso que parecían provocar síntomas negativos y, posteriormente, el colapso de la conexión terapéutica con un paciente que experimenta FEP. El caso examinado fue el de una psicoterapia de 6 meses que fue parte de un estudio piloto que examino el uso de la terapia metacognitiva de reflexión y percepion (MERIT por sus iniciales en inglés). Identificamos cuatro códigos prominentes en 24 transcripciones de psicoterapia que parecían provocar síntomas negativos e interrumpir la conexión terapéutica: relación terapéutica, desafíos del terapeuta, apoyos del terapeuta y avisos del terapeuta. Proponemos que la aparición de síntomas negativos en sesión no es simplemente una consecuencia de la psicopatología, sino que parece ser una respuesta a la dinámica interpersonal que se produce entre el terapeuta y el paciente. Esto puede requerir apertura por parte del terapeuta para atender y considerar el significado potencial detrás de estos síntomas negativos que surgen durante la sesión. ?????????:??????????????????? ??????????????????????????,????????(FEP)????????????????????FEP?????????????,????????????????????,???????????????????,???FEP???????????????????????????,????????????????????????????????????????????,?????????????,????????,???????????????,?????FEP?????????????????????6???????,?????????????,??????FEP???????????(MERIT)?FEP????????????24????????????????,???????????????????:????,?????,????????????????????????????????????????,????????????????????????????????????,????????????????????????????