Metacognitive Reflection And Insight Therapy Research Articles

Psychotherapy to emphasize self-directed recovery for persons with serious mental illness: Contributions from metacognitive reflection and insight therapy (MERIT).

Recovery from serious mental illness (SMI) is a complex process that can be supported by different levels of mental health care, for example, individual psychotherapy. Current individual evidence-based psychotherapy for persons with SMI is often focused on specific objective recovery outcomes, including symptom reduction and functional improvement, and requires a minimum level of insight. Less common but also important are broader, more flexible approaches that allow clients to explore their needs and challenges, without predetermined goals or a certain level of insight. The current article aims to describe (1) the development of metacognitive reflection and insight therapy (MERIT), an evidence-based psychotherapy that is focused on self-determination, or self-directed recovery, and (2) how MERIT advances care for persons with SMI by addressing a significant gap in the field for the treatment of people with SMI with limited metacognitive capacity and insight, offering an adaptable approach emphasizing self-directed recovery. MERIT utilizes a metacognitive framework that is guided by flexible key elements and an interpersonal environment. Training MERIT therapists early in their careers may be helpful in providing a holistic view of SMI to promote self-directed recovery in ways that are personalized and meaningful for each person. MERIT training has been completed in multiple countries across different levels of training (e.g., internship and psychology practicum). Professionals such as psychologists and social workers have effectively played a role in MERIT development and dissemination, which ultimately strives to advance psychotherapy for a wide range of individuals with SMI. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Metacognition as a Transdiagnostic Determinant of Recovery in Schizotypy and Schizophrenia Spectrum Disorders.

The term schizotypy refers to the latent personality organization that is thought to underpin the liability to develop schizophrenia and associated disorders. Metacognition, or the ability to understand and form increasingly complex and integrated ideas of oneself, others, and one's community, has been proposed to be an important transdiagnostic construct across schizophrenia spectrum disorders and a range of both clinical and non-clinical manifestations of schizotypy. In this paper, we review evidence that deficits in metacognition are present in individuals with relatively high levels of schizotypy and that these deficits are related to symptomology, function, and quality of life. We address the idea that decrements in metacognition may also contribute to the progression from schizotypy to more severe manifestations, while the amelioration of these deficits may enhance aspects of recovery, including the ability to form an integrated sense of self, others, and the wider world. We also review the following two recovery-oriented psychotherapies that target metacognition to promote recovery in individuals with clinical manifestations of schizotypy: Evolutionary Systems Therapy for Schizotypy (ESTS) and Metacognitive Reflection and Insight Therapy (MERIT).

A Recovery-Oriented Approach: Application of Metacognitive Reflection and Insight Therapy (MERIT) for Youth with Clinical High Risk (CHR) for Psychosis.

Clinical High Risk for psychosis (CHR) refers to a phase of heightened risk for developing overt psychosis. CHR often emerges during adolescence or early adulthood. CHR has been identified as a group to target for intervention, with the hope that early intervention can both stave off prolonged suffering and intervene before mental health challenges become part of an individual's identity. However, there are few treatment modalities that can address some of the specific needs of CHR. Metacognitive Reflection and Insight Therapy (MERIT) is an integrative psychotherapy that can be applied to the CHR population. MERIT offers unique advantages to working with the CHR population as it aims to improve self-direction and recovery through stimulation of metacognitive capacity, a phenomenon that has been associated with recovery. This paper explores unique aspects of the CHR population and how MERIT can address barriers to recovery for individuals experiencing psychosis-like symptoms. Several case examples and a clinical vignette using MERIT to support patients with CHR are offered to exemplify this approach. MERIT offers a way to assist persons with CHR to address barriers to their personal recovery and to develop nuanced understandings of ways to master challenges.

Psychotherapy on an Acute Psychiatric Ward: Preliminary Findings From a Controlled Study.

This study investigated the efficacy of psychotherapy during hospitalization on an acute psychiatric ward. A controlled trial was conducted to assess the effects of Metacognitive Reflection and Insight Therapy (MERIT) upon metacognition and psychiatric symptoms. Data from 40 inpatient women were analysed. Findings included significant interaction effects between group (intervention or control group) and time (preintervention and postintervention) in regard to the metacognitive abilities and general psychiatric symptoms. Participating in MERIT seems to improve one's ability to use reflective knowledge to cope with psychological challenges and to improve symptomatology level.

Translating an integrative metacognitive model of psychotherapy for serious mental illness into a group format: A pilot investigation on feasibility.

Metacognitive reflection and insight therapy (MERIT) is an one-on-one intervention that targets insight with the aim to help people with serious mental illness develop more integrated ideas about themselves and others in order to respond to their psychological and social challenges more adaptively. There is a growing body of evidence on MERIT's effectiveness. Considering the clinical demand for more cost-effective group psychotherapies, we modified the original individual MERIT format to a group-based intervention (MERITg) for application in inpatient and outpatient psychiatric settings. Thirty-one participants (inpatient = 10; outpatient = 21) with serious mental illness were surveyed on their experience of MERITg, which was offered adjunctively to their routine clinical care. Program evaluation measures were used to assess the feasibility and acceptance of the group. Across locations, more than half of all participants attended more than one group. Participants reported attending the group initially because they thought writing would be helpful, and further reported that they liked the group because they enjoyed writing and the discussion, and that they found it interesting to hear the perspectives and writings of others. Findings further support the need for future research on the efficacy and effectiveness of the group and its relationship to changes in metacognitive capacity and recovery. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Promoting Meaning and Recovery for Psychosis: Comparison of Metacognitively-Oriented Psychotherapists and Clinicians in Psychiatric Rehabilitation.

Recovery from psychosis is an expected and desired outcome in psychiatric rehabilitation that may involve subjective outcomes related to personal recovery. While a considerable amount of qualitative research has examined patients' experience of recovery oriented approaches, there are less studies examining clinicians' perspectives. Examining the clinician point of view is important for both supporting clinicians within recovery-oriented practice, as well as for understanding underlying therapeutic processes. The aims of this study were to explore clinician experience of offering different psychiatric rehabilitation treatments for individuals with psychosis, and to understand similarities and differences of clinicians whose work differed in its recovery emphasis. Open-ended interviews were conducted with 10 psychotherapists providing Metacognitive Reflection and Insight Therapy (MERIT), a recovery oriented form of integrative psychotherapy focused on subjective aspects of recovery, and 10 clinicians providing standard psychiatric rehabilitation services. Thematic analysis revealed important similarities and differences between these two groups of providers. There were seven themes found for MERIT therapists: Comfort with uncertainty, Emphasis on collaboration, Being part of therapeutic change, Connecting with clients, Emphasis on patient autonomy, Experiencing growth, and Therapist use of self-awareness. There were four themes found for psychiatric rehabilitation clinicians: Value of a structured approach, Focus on a strengths-based approach, Witnessing behavioral change, and Building rapport to support the work. As expected, both similarities and differences arose between clinician groups. Results indicated that both groups focused on the therapeutic relationship and monitoring progress and outcomes. Unexpectedly, MERIT therapists reported growth as well as comfort with uncertainty. These findings suggest that MERIT is a a psychotherapy that offers unique opportunities for creative and flexible exploration of meaning and agency that is both challenging and rewarding for clinicians. Implications for supporting healthy clinician practice and the development of services are discussed.

Findings from a randomized controlled trial of Metacognitive Reflection and Insight Therapy for people with schizophrenia: Effects on metacognition and symptoms

AbstractBackgroundResearch has suggested that people diagnosed with schizophrenia experience challenges in their abilities to reflect upon themselves, others and their actions in the world. One emerging approach to addressing these forms of subjective disturbance is Metacognitive Reflection and Insight Therapy (MERIT).AimsIn this study, a randomized delayed trial was conducted to assess the effects of MERIT upon metacognition, psychiatric symptoms and quality of life.Materials and MethodsFollowing recruitment and randomization, data from 54 adults diagnosed with schizophrenia were analysed.ResultsFindings included significant interaction effects between group (immediate intervention or waiting condition) and time (pre‐ and post intervention) with regard to the metacognition general score and its domain of mastery, as well as with regard to negative, positive and cognitive symptoms.DiscussionParticipating in MERIT seems to improve one's ability to use reflective knowledge to cope with psychological challenges and to improve, or at least maintain, level of symptomatology.ConclusionsThese findings are discussed within the framework of agency as an important aspect of recovery.

"Metacognitive Reflection and Insight Therapy" (MERIT) for the Occupational Therapy Practitioner.

Background. Metacognitive Reflection and Insight Therapy (MERIT) is a manualized, evidence-based approach that supports occupational participation through its focus on the inter-related constructs of meaning making, positionality, and self-definition (Lysaker et al., 2020). MERIT's core tenets parallel the fundamentals of occupational therapy, making it an ideal guiding methodology for mental health occupational therapy practice. Purpose. We outline key constructs of MERIT and detail how occupational therapy practitioners can apply MERIT to support occupational engagement. Key Issues. Few manualized, evidence-based interventions exist to guide occupational therapy mental health practice (Kirsch et al., 2019). Detailing MERIT and its application in occupational therapy is an important first step in future studies of its feasibility, acceptability, and effectiveness in this context. Implications. MERIT provides a clear methodology for delivering mental health occupational therapy services that is amenable to large-scale hybrid implementation and effectiveness studies, thereby supporting practice and rigour in research.

Emotional experience and metacognition among people with schizophrenia: Analysis of session by session and outcome of metacognitive-oriented psychotherapy

BackgroundResearch suggests that in-session emotional experiences in psychotherapy promote both session and treatment outcomes across different clinical samples and treatment approaches. However, little is known about how this notion applies to clients with schizophrenia, who experience particular deficits related to emotional experience. To explore this question, we investigated the association between clients' emotional experience and their session outcome evaluations and metacognitive growth in a metacognitively-oriented treatment, Metacognitive Reflection and Insight Therapy (MERIT). MERIT is a recovery-oriented treatment approach for psychosis that focuses on recapturing a coherent sense of self and personal agency by enhancing metacognitive capacity. MethodFive-hundred-and-sixty-three sessions of 37 clients with schizophrenia who took part in an ongoing MERIT trial were analyzed. The Emotional Experience Self-Report (EE-SR) and Outcome Rating Scale (ORS) were collected on a session-by-session basis. Levels of metacognition ware assessed pre- and post-treatment using the Metacognitive Assessment Scale-Abbreviated (MAS-A) coding system. We used multilevel modeling to test our session-level predictions, and linear regression analysis for treatment-level predictions. ResultsGreater emotional experience, expression, and regulation within a session were associated with better session outcome. Regarding treatment level, greater emotional experience was associated with improvement in metacognitive mastery. ConclusionsOur findings reveal that experiencing emotions in MERIT has significant implications for clients' subjective well-being during therapy sessions and for their ability to respond to psychological challenges using metacognitive knowledge. These findings lend weight to the idea that emotional experience is a key mechanism of change in metacognitive therapy for schizophrenia.

Re-owning Motherhood in Metacognitive Reflection and Insight Therapy (MERIT) with A Woman Diagnosed with Schizophrenia: Lessons from A Case Study

Re-owning Motherhood in Metacognitive Reflection and Insight Therapy (MERIT) with A Woman Diagnosed with Schizophrenia: Lessons from A Case Study

Finding the Person in the Disorder: Adapting Metacognitive Reflection and Insight Therapy for Bipolar Mood Disorder (MERIT-BD)

Metacognitive Reflection and Insight Therapy (MERIT) was originally developed as an integrative recovery-oriented therapeutic approach to address the needs of people with a diagnosis of schizophrenia and other forms of severe mental illness. The approach, conceptualized as transtheoretical, aims to promote a more coherent and synthetic sense of self, through stimulating insight, sense of coherence, and metacognitive capacity. We argue that MERIT therapy, designed to facilitate peoples’ ability to form complex ideas about themselves and others and to use this knowledge to respond to psychological problems, has application in addressing deficits associated with bipolar disorder (BD), where there may be a significant injury to the person’s sense of self. That is, the therapy addresses the nascent sense of self in a context where disturbance of mood is dominant, and in relation to the experience of episodic manic episodes which may be understood as dissociative events, often associated with shame. The application of the therapeutic approach, which we term MERIT-BD draws upon MERIT’s primary principle of facilitating complexity and integration of the self, and additionally addresses shame, allowing for the facilitation of metacognitive capacity and insight in the context of finding the person. This approach will be illustrated with case vignettes illustrating the application of key components of MERIT-BD. Early findings drawn from a series of case studies are encouraging.

Metacognitive Reflection and Insight Therapy (MERIT) Delivered Virtually During the COVID-19 Pandemic: An Illustration of Two Cases.

Alternative platform offerings for psychotherapy have become a necessity in the age of the novel coronavirus (COVID-19) pandemic. The current study describes the virtual adaptation of Metacognitive Reflection and Insight Therapy (MERIT) for people with psychosis. MERIT is a recovery-oriented psychotherapy that has shown promise in increasing metacognition and allowing individuals to make meaning of their psychiatric challenges and direct their own recovery efforts. MERIT delivery requires the assumption that metacognitive reflection is an intersubjective act where individuals make meaning with others instead of in isolation. As such, considering the current COVID-19 pandemic, research is needed to understand how intersubjectivity and the therapeutic alliance may differ in a virtual environment rather than in-person. The present study addresses this question by illustrating two case examples of MERIT’s adaptation to a virtual delivery telehealth format. Moreover, this study expands on Lysaker and colleagues’ (2020) investigation of virtual adaptations of MERIT by exploring how MERIT is adapted in a virtual environment, how intersubjectivity changes in a virtual environment, and, what opportunities virtual platforms allow for metacognitive reflection. Overall, we found that MERIT can be successfully delivered in a virtual telehealth platform. We discuss opportunities and considerations for MERIT and other psychotherapy virtual delivery.

Personalizing interventions using real-world interactions: Improving symptoms and social functioning in schizophrenia with tailored metacognitive therapy.

When clients' lives are not reflected in therapy, they struggle to apply the skills learned in treatment to everyday situations. In this pilot study, we determined if using clients' real-world interactions in therapy could effectively target metacognitive capacity-yielding improved symptoms and social functioning-by tailoring treatment to focus on issues faced by clients in daily life. Using a randomized controlled trial design, schizophrenia subjects with metacognitive deficits completed 24 sessions of: (a) Standard Metacognitive Reflection and Insight Therapy (MERIT); or (b) Tailored MERIT. Real-world interactions were captured via the Electronically Activated Recorder (EAR), a smartphone application that passively records audio in daily life. All subjects wore the EAR; however, real-world interactions were only used to personalize sessions in Tailored MERIT. Feasibility and acceptability were shown; those in Tailored MERIT wore the EAR 84% of their waking hours and reported minimal burden. When compared to Standard MERIT, Tailored MERIT participants showed large pre-post reductions in negative metacognitive beliefs and disorganized symptoms. Small, but nonsignificant, improvements in social functioning were also observed. Compared to an evidence-based benchmark, we observed that real-world interactions can be used to tailor metacognitive therapy and improve outcomes in schizophrenia. Tailored MERIT has the potential to impact practice by personalizing treatment to account for individual variations in environment and lifestyle-aligning with the Precision Medicine Initiative-in a way that is not possible with current therapy. This is particularly salient in schizophrenia, where limited insight and cognitive deficits often make subjective reporting unreliable. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Addressing negative symptoms in schizophrenia through Metacognitive Reflection and Insight Therapy: An illustrated Case Study

The resistance of negative symptoms to pharmacologic treatment has spurred interest in understanding the psychological factors that contribute to their formation and persistence.Accordingly, recent research has suggested that deficits in metacognition, or the ability to form integrated ideas about oneself, others and the world, are involved in the development and maintenance of negative symptoms. One implication of this work is that treatments which address metacognition may effectively lead to reduction in negative symptoms. This paper explores the application of one such treatment, designed to address deficits in metacognition, Metacognitive Reflection and Insight Therapy (MERIT), to addressing persistent negative symptoms. First the basic principles of MERIT are presented and then its potential to address negative symptoms is illustrated by a comprehensive case report.

Can metacognitive interventions improve insight in schizophrenia spectrum disorders? A systematic review and meta-analysis

Patients with schizophrenia spectrum disorders (SSD) tend to lack insight, which is linked to poor outcomes. The effect size of previous treatments on insight changes in SSD has been small. Metacognitive interventions may improve insight in SSD, although this remains unproved. We carried out a systematic review and meta-analysis of randomized controlled trials (RCTs) to examine the effects of metacognitive interventions designed for SSD, namely Metacognitive Training (MCT) and Metacognitive Reflection and Insight Therapy (MERIT), on changes in cognitive and clinical insight at post-treatment and at follow-up. Twelve RCTs, including 10 MCT RCTs (n = 717 participants) and two MERIT trials (n = 90), were selected, totalling N = 807 participants. Regarding cognitive insight six RCTs (n = 443) highlighted a medium effect of MCT on self-reflectiveness at post-treatment, d = 0.46, p < 0.01, and at follow-up, d = 0.30, p < 0.01. There was a small effect of MCT on self-certainty at post-treatment, d = -0.23, p = 0.03, but not at follow-up. MCT was superior to controls on an overall Composite Index of cognitive insight at post-treatment, d = 1.11, p < 0.01, and at follow-up, d = 0.86, p = 0.03, although we found evidence of heterogeneity. Of five MCT trials on clinical insight (n = 244 participants), which could not be meta-analysed, four of them favoured MCT compared v. control. The two MERIT trials reported conflicting results. Metacognitive interventions, particularly Metacognitive Training, appear to improve insight in patients with SSD, especially cognitive insight shortly after treatment. Further long-term RCTs are needed to establish whether these metacognitive interventions-related insight changes are sustained over a longer time period and result in better outcomes.

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.

The Psychotherapeutic Treatment of Schizophrenia: Psychoanalytical Explorations of the Metacognitive Movement

Metacognition refers to the set of activities which allow persons to have a sense of oneself and of others available to them within the flow of daily experience. These activities range from awareness of discrete aspects of experience to their synthesis into larger, more complex ideas. Following research documenting the existence and influence of metacognitive deficits in schizophrenia, psychotherapeutic frameworks have emerged aiming to improve metacognition in this group. Metacognitive Reflection and Insight Therapy (MERIT) is one such integrative psychotherapy framework. Therapeutic targets and principles of MERIT are intended to be integrative but share common characteristics with psychoanalytical tradition in the treatment of schizophrenia. This paper accordingly explores how psychoanalytic theory can help explain how the effects of MERIT upon metacognition and self-experience in schizophrenia may reflect its effects on repairing the collapse of the boundary/connection between self and the world, mental fragmentation, and the lack of symbolization.

Metacognition and recovery in schizophrenia: From research to the development of metacognitive reflection and insight therapy

Metacognition refers to a spectrum of activities which spans from noticing discrete experiences to synthesizing them into a larger sense of the self and others. Evidence suggesting that deficits in metacognition are broadly present in schizophrenia and represent a potent barrier to recovery from schizophrenia has led to increasing interest in the development of metacognitively oriented treatments. In this article, we will describe the development of one such treatment, metacognitive reflection and insight therapy (MERIT), an integrative form of psychotherapy defined by eight core elements. We will first discuss the concept of metacognition as a means to operationalize the processes which enable persons to have a sense of themselves and others available for reflection and that can then serve as the basis for effective and agentic responses to psychosocial challenges. We will then discuss methods for assessing metacognition, the development of MERIT as a treatment that targets metacognition, and how MERIT compares with other treatments. Next, we will discuss empirical support for MERIT’s role in recovery including its potential to assist persons to develop their own personally meaningful sense of their challenges and then decide how to effectively respond to those challenges and manage their own recovery.

A qualitative evaluation of the effects of Metacognitive Reflection and Insight Therapy: 'Living more consciously'.

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. 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. 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. 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. 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 (MERIT) for patients with schizophrenia

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. 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). 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. 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.