Metacognitive Reflection and Insight Therapy: a Recovery-Oriented
Total Page：16
File Type：pdf, Size：1020Kb
Psychology Research and Behavior Management Dovepress open access to scientific and medical research Open Access Full Text Article REVIEW Metacognitive Reflection and Insight Therapy: A Recovery-Oriented Treatment Approach for Psychosis This article was published in the following Dove Press journal: Psychology Research and Behavior Management Paul H Lysaker 1,2 Abstract: Recent research has suggested that recovery from psychosis is a complex process Emily Gagen 3 that involves recapturing a coherent sense of self and personal agency. This poses important Reid Klion4 challenges to existing treatment models. While current evidence-based practices are designed fi Aieyat Zalzala5 to ameliorate symptoms and skill de cits, they are less able to address issues of subjectivity fl Jenifer Vohs2 and self-experience. In this paper, we present Metacognitive Insight and Re ection Therapy (MERIT), a treatment approach that is explicitly concerned with self-experience in psycho- Laura A Faith1,6 2,7 sis. This approach uses the term metacognition to describe those cognitive processes that Bethany Leonhardt fi 7 underpin self-experience and posits that addressing metacognitive de cits will aid persons Jay Hamm diagnosed with psychosis in making sense of the challenges they face and deciding how to 8 Ilanit Hasson-Ohayon effectively manage them. This review will first explore the conceptualization of psychosis as 1Richard L. Roudebush VA Medical the interruption of a life and how persons experience themselves, and then discuss in more 2 Center, Indianapolis, IN, USA; Indiana depth the construct of metacognition. We will next examine the background, practices and University School of Medicine, Indianapolis, IN, USA; 3Providence VA evidence supporting MERIT. This will be followed by a discussion of how MERIT overlaps Medical Center Department of with other emerging treatments as well as how it differs. MERIT’s capacity to engage 4 Psychology, Providence, RI, USA; MERIT patients who reject the idea that they have mental illness as well as cope with entrenched Institute, Boulder, CO, USA; 5Institute of Living, Hartford, CT, USA; 6University of illness identities is highlighted. Finally, limitations and directions for future research are Missouri - Kansas City, KS, USA; discussed. 7Eskenazi Health- Midtown Community Keywords: schizophrenia, psychosis, metacognition, rehabilitation, psychotherapy, recovery Mental Health, Indianapolis, IN, USA; 8Bar Ilan University, Ramat-Gan, Israel Introduction The past several decades have seen a resurgence of interest in understanding the experience and course of psychosis. This has included quantitative and qualitative studies, longitudinal and cross cultural research, work taking place in traditional academic centers as well as community-led and grass roots movements focused on first person experiences of psychosis.1–3 Taken as a whole, this work has cast considerable doubt on many long-standing assumptions. For example, the once axiomatic belief that psychosis has necessarily a progressively negative and detri- mental course has been categorically rejected. In its place, assertions have arisen that recovery is an attainable outcome for many.4 Ideas about the processes that promote recovery have also evolved. The belief Correspondence: Paul H Lysaker that recovery largely results from improvements in insight and compliance with Richard L. Roudebush VA Medical Center, 5 Department of Psychiatry 116A, 1481 pharmacological treatment has been challenged by a growing body of evidence West 10th Street, Indianapolis, IN IN that recovery is enabled by connections with one’s community6 and not necessarily 46202, USA 7,8 Email [email protected] continuous pharmacological treatment. The essence of what defines and submit your manuscript | www.dovepress.com Psychology Research and Behavior Management 2020:13 331–341 331 DovePress © 2020 Lysaker et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms. – http://doi.org/10.2147/PRBM.S198628 php and incorporate the Creative Commons Attribution Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). Lysaker et al Dovepress constitutes recovery has been recognized as far more com- which involve significant disruptions in thought, emotion, plex than the absence of disorder and disability.3 The behavior and community integration. concept of recovery has been expanded to explicitly include, for example, changes in how persons experience The Conceptualization of Psychosis themselves as beings in the world. To some, recovering as the Interruption of a Life and can mean recapturing of a sense of agency and a cohesive Persons’ Experience of Themselves sense of self.2,9 Recovery can include experiences that are Persons diagnosed with psychosis may understand recov- difficult to quantify or observe by others, because as ery in ways that are private, immediate and not directly fundamentally subjective matters they can only be known observable by others. While the recovering person and by the recovering person.10–12 others around them might both notice a positive change This growing work on recovery has pointed to the need in employment or educational status, the renewal of social to revisit the purposes and mechanisms of mental health relationships, or the absence of inexplicable experiences treatment. If deeply subjective change is at issue, then (i.e., hallucinations), the recovering person alone can teaching skills and reducing symptoms may not go far notice if something about how they experience themselves enough in promoting recovery. But how could outcomes in the world has changed. In this way, the recovering such as subjective changes in sense of agency and sense of person’s self-experience is something only available to fl self be addressed? Metacognitive Insight and Re ection them at the moment and not something others can unilat- 13,14 Therapy (MERIT), an integrative form of psychother- erally make decisions about (e.g., whether or not recovery apy, is one treatment which has sought to directly address “has happened”). processes which may underpin some of the more subjec- William James,17 among the first psychologists to com- tive aspects of recovery. MERIT focuses on metacognitive prehensively explore self-experience, suggested that we do capacity, the measurable cognitive processes which enable not just experience the world, we experience ourselves us to understand ourselves and others in a flexible and experiencing the world. Our self-experience becomes evolving fashion and so support a sense of agency and more than just another object we can think about. When cohesive sense of self. MERIT thus explicitly seeks to we experience ourselves experiencing the world, we also enable recovering persons to make sense of and effectively experience ourselves responding to that experience and manage challenges they face by promoting metacognitive making interpretations. Our experience of our responses capacity.15 and interpretations are also not negligible abstractions. While previous work has described some formal They are the basis for deciding how to understand and aspects of MERIT,13,14 the ways in which MERIT attempts manage what is unfolding before us. to address the issues raised above regarding recovery have Given this context, what is at issue in psychosis and its not been discussed in great detail. To examine this, the resolution is not just what people experience, but also how current review will explore the background, practices, and people experience themselves. Psychosis is more than just supporting evidence for MERIT. To provide context, we strange experiences or social challenges. As noted above, will first offer a brief overview of the issue of subjectivity a healthy life following psychosis may not emerge even in recovery from psychosis. We will then detail how when ostensible disease markers (e.g., hallucinations) are MERIT is constructed as an integrated practice and then no longer present or when the individual demonstrates provide a summary of research supporting its effectiveness satisfactory “life skills.” Since disorder and disability in treating psychosis. We next discuss how it converges represent an interruption of a life and how a person experi- and diverges from other psychotherapies including emer- ences themselves as they live that life, recovery is better ging forms of cognitive therapy and how it uniquely han- understood as a resolution of that interruption. dles a number of clinical challenges. Finally, we will explore key research issues facing this and other recovery- Metacognition, Self-Experience in oriented treatments. We recognize international debate Psychosis and MERIT about the usefulness and accuracy of terms such as These conceptualizations of recovery offer a formidable schizophrenia.16 As a result, we use the term psychosis set of challenges to mental health treatment and psy- to capture a broad range of forms of serious mental illness chotherapy in particular. What do changes in how persons 332 submit your manuscript | www.dovepress.com Psychology Research and Behavior Management 2020:13