Metacognitive Reflection and Insight Therapy for Persons With Severe Negative Symptoms of Schizophrenia

Hahn is a Caucasian male in his early thirties. Hahn was born in a rural American town but moved around several states throughout his childhood because of his father’s career as a traveling salesman. Hahn was raised by his mother and father and had one older brother and one younger sister. He stated that he had positive relationships with his parents growing up but said that his parents were often absent during his childhood because his father was an alcoholic and his mother often spent a significant amount of time taking care of her husband. Hahn reported that he was close to his siblings growing up but that he spent much of his childhood alone because his parents were often gone and his siblings were older and spent time with their own friends. He described how he would often leave his house in the morning and spend time at a variety of his friends’ houses in the neighborhood and then come home and cook dinner for himself. There was no indication of a family history of mental illness or any physical or sexual abuse.

When Hahn was 14 years old, his brother was in a serious automobile accident that left him in a coma for a year. Hahn reported that he would often visit his brother in the hospital, and he described a vivid memory in which he watched his brother lying in the hospital bed and wondered if he would ever hear his brother’s voice again. He stated that his parents started taking Hahn to a therapist during this time. However, Hahn reported that he does not know how long he was in therapy and does not remember the content of these sessions. Hahn stated that when he first started high school, he studied quite a lot and noted that science was his favorite subject because he enjoys solving mysteries. However, he stated that by 11th grade, he started “hanging out with the wrong crowd” and would often skip class, come to class late, and drink with his friends on weekends. He eventually dropped out of high school during 12th grade.

Hahn had his first significant romantic attachment after he dropped out of high school. He referred to this girlfriend as a “bad influence” and said that he continued to drink on weekends and weeknights to the point that his parents eventually kicked him out of his house. He noted that he stayed at different friends’ houses for a period before he eventually broke up with his girlfriend and moved back in with his parents. He then worked at a fast-food restaurant for several months. He reported that this was his favorite job he has ever held because he got to make sandwiches all day and knew exactly what he needed to do. It should be noted that these autobiographical details of Hahn’s life were initially unknown to the therapist; however, through the use of MERIT, rich narratives of Hahn’s life began to emerge.

Hahn enlisted in the Navy in 2008 and was deployed to Iraq in 2009. Hahn denied having any symptoms prior to entering the service. His main role in the Navy was serving as a cook, and he said that he enjoyed this role and enjoyed talking about sports with the other cooks in the kitchen. However, it appears that he started to develop prodromal symptoms of psychosis a few months after his deployment to Iraq. Specifically, he mentioned hearing generalized noises, such as the noises of a crowd, almost consistently throughout the day. He stated it was during this time that he started seeing the Navy psychiatrist and remembers being asked many questions about the future and about his behaviors. After he started seeing the Navy psychiatrist, Hahn noticed that his workload in the Navy was being lessened. He was no longer allowed to cook in the kitchens and instead was often given tasks such as delivering packages or cleaning. In addition, he reported that his uniform and gun were taken away, and he was no longer allowed to train with his unit.

Hahn reported that he continued to meet with the psychiatrist until one day when he was asked hundreds of yes-or-no questions. Shortly after this evaluation, he was flown out of Iraq to a psychiatric hospital in the United States. He described often wondering why he was no longer allowed to interact with the friends in his unit and why he was no longer allowed to cook in the kitchen. When he mentioned these thoughts, an expression of pain and confusion was often etched on his face. After staying in a psychiatric hospital in the southern United States, Hahn moved back to the town in which his family lived and started coming to the Department of Veterans Affairs (VA) hospital in that city. Hahn began psychotherapy and continued to take sertraline and risperdal, which were prescribed by his Navy psychiatrist. When Hahn began psychotherapy, he presented with a range of negative symptoms, including blunted affect, slowed and delayed speech, poverty of thought, psychomotor retardation, and avolition. He often would lapse into prolonged silences and spent a significant portion of earlier sessions avoiding eye contact with his therapist and staring at his hands.

In earlier sessions with the current therapist, he often began by assuring the therapist that he had taken his medication and by denying any psychological problem. He would then recite the daily tasks he had carried out for the past week (went to the grocery store, mowed the lawn), without acknowledging any struggle in completing these tasks. In addition, he seemed anxious during any silences that developed in the therapy room and would often start repeating his report of tasks he had completed since the previous session.

Diagnostically, Hahn met full criteria for schizophrenia, because he displayed catatonia as well as a range of negative symptoms for an extended period. He had little or no interest in the world and presented with anhedonia in the absence of depression. He expressed no emotions in the session, and it was initially quite difficult for the therapist to feel engaged or connected with Hahn. In addition, he displayed a paucity of thought content and initially spent the most of the early sessions reciting lists of tasks he had completed in the past week, with little room for reflection or exploration of his thoughts. He appeared unable to or disinterested in sustaining any type of goal-directed activity and often spent days at a time in his room watching television or sitting on his porch watching his neighbors go about their lives. These negative symptoms and Hahn’s blank and disinterested presentation posed a significant challenge for therapy, and, at times, it seemed to the therapist that any thought of change or mutual exploration of Hahn’s thoughts would be hopeless.

No drug use was reported, and although Hahn reported that he often drinks on weekends, he typically has only two beers with his brother. No general medical conditions were reported. In regard to psychosocial functioning, there appears to have been a significant shift in his functioning after his diagnosis when he was in the Navy. Hahn mentioned having numerous friendships in high school, but he appears to have no significant relationships apart from his connections to his family. He often experiences confusion when wondering about the loss of these previous friendships. Although he reported working a number of jobs in high school and prior to enlisting, Hahn was unable to maintain a job for years after his diagnosis. Notably, during his time with his previous therapist, he was able to begin working again through a vocational rehabilitation program in the VA. Although Hahn expresses the wish to work and repeatedly mentions wanting to reconnect with previous friends, he appears to lack the ability to see himself as an agent who is capable of sustaining goal-directed activity.

Hahn’s metacognitive capacity was assessed by using the four scales of the Metacognition Assessment Scale–Abbreviated (MAS-A) (8, 20): self-reflectivity (S), understanding the mind of the other (O), decentration (D), and mastery (M). The MAS-A is an adaptation of the MAS (8). Toward the beginning of psychotherapy, Hahn’s ability to self-reflect was limited; he was able to recognize his own thoughts but was limited in his capacity to recognize a variety of internal states (such as wondering, hoping, or imagining). In addition, he was unable to identify a nuanced range of emotion; he often described himself as feeling “good” or “okay.” Hahn’s capacity of other-reflectivity was also limited; he was able to recognize that others had thoughts but was unable to identify or differentiate between the range of internal states that others experienced.

Regarding decentration, Hahn was unable to recognize that others may have perspectives apart from his own perspectives, because he often replied, “I don’t know what he was thinking,” when asked about the mental states of others. In addition, he did not see himself as the center to others’ lives, yet he struggled to imagine the lives of others apart from him. In regard to mastery, Hahn initially struggled to identify a psychological problem, because it seemed he wanted to appear “healthy” or “normal” to the therapist. He would often deny any psychological problem or would recite specific diagnoses, such as “My depression is not as bad.” Hahn was able to recognize some level of internal distress; however, he was unable to identify a psychological problem in a nuanced or genuine way with a plausible origin. Translated into scores on the MAS-S, Hahn was assessed as follows: S, 2.5 out of 9.0; O, 2.0 out of 7.0; D, 0.5 out of 3.0; and M, 1.5 out of 9.0. (Higher scores indicate greater capacities to synthesize discrete pieces of information into an integrated representation.)

This element refers to the importance of considering and being attentive to the patient’s agenda in the session. The patient’s agenda refers to his or her thoughts, wishes, dreams, and desires that are inherently present in every session. In addition, the therapist must recognize that patients may hold several agendas at once and that these agendas may shift throughout session. Furthermore, patients may not always be aware of their agendas.

Toward the beginning of the session, the therapist struggled to understand what Hahn’s agenda was. Hahn would often begin by stating that everything was okay and that he was taking his medicine. He would then begin to recite the daily tasks he had completed during the past week. For example, he would describe how he had recently mowed the lawn, gone to the gas station, and watched television. Although Hahn was responsive to any question the therapist asked, he would often simply respond to a question and then return to the recitation of his weekly activities. It was hypothesized that Hahn’s early agenda was to convince the therapist that he was “normal” and that he was being a “good” patient by consistently taking his medication. As mentioned previously, Hahn saw a psychiatrist in the Navy, and as a result of a psychiatric evaluation, his workload was reduced and he was eventually medically discharged from the Navy. Thus, it is possible that at the beginning of psychotherapy, Hahn wanted to assure the current therapist that he was normal and healthy to avoid any negative consequences.

The therapist often worried whether she was being helpful to Hahn; yet, rather than attempting to impose any type of structure onto the session, the therapist would sit with her feelings of confusion and listen carefully to the thoughts Hahn brought into therapy. When Hahn described the tasks he had completed during the previous week, she responded with curiosity and asked for details regarding these activities. Furthermore, when Hahn repeatedly mentioned he was “healthy” and “good” and taking his medication, the therapist would reflect, “It’s important that I know you’re feeling good.” In addition, the therapist would ask Hahn questions about how the session went and whether it went how he expected. These questions (which are described in more detail in element 6) led Hahn to reflect on his agenda and helped the therapist better understand Hahn’s uncertainty in the session. In addition, the application of this element encouraged Hahn to notice his intents and wishes in the session and positioned him as an agent in therapy, a role that challenged his passive stance toward the world and those around him, which was a result of his negative symptoms.

As time progressed, Hahn began to view therapy as a place to know his own mind. He would often bring up the thoughts he had experienced during the week, often mentioning that his thoughts felt “cloudy,” which often made him sleepy. In addition, he began to link past therapy sessions in his mind and would say that he had thought about content from previous sessions and wanted to explore this content further in the current session. At times, it appeared that Hahn saw the therapist as an arbiter of reality or as a judge of normality, because he would often bring up thoughts he had experienced or memories he had recalled and question whether the memories were real or if they were “crazy.” Thus, it appeared that Hahn’s agenda shifted to one of wanting to better understand himself and his mental states and to using the therapy sessions to make sense of his mind. Instead of passing any type of judgment on the content of Hahn’s memories, the therapist would encourage Hahn to describe these memories in detail and share the emotions he felt when experiencing and describing them in an effort to maintain an open stance, which promoted exploration over judgment.

The second element of MERIT encourages the therapist to share his or her own thoughts in a meaningful way that stimulates collaborative dialogue within the session. By the therapist’s making his or her mind present within session, the patient is encouraged to recognize and reflect on the mind of the other, which increases metacognitive capacity. In addition, this approach supports a collaborative, nonhierarchical approach to therapy, which reduces the stigma that many patients experience during therapy.

Toward the beginning of therapy, Hahn often seemed uncomfortable and thrown off balance with the introduction of the therapist’s mind in the session. For example, as mentioned above, during earlier sessions, Hahn often spent most of the time discussing his weekly activities. If the therapist asked Hahn a question during this recitation, it seemed to interrupt the flow of his thoughts, and he often became noticeably uncomfortable (for example, fidgeting more and stuttering), and the pauses between his words would increase. Thus, during this time, the therapist was careful not to be too active in the session by asking the patient too many questions or introducing many of her own thoughts. Instead, she often made comments such as, “It sounds like you are having a lot of thoughts today” or “It seems like when I speak, it upsets your thinking.” These types of comments seemed less intrusive and threatening to Hahn, because he was able to continue his flow of thoughts and reflect on how “cloudy” or “clear” his thoughts felt that day.

As therapy progressed, Hahn appeared to better tolerate the insertion of the therapist’s mind in the session in the form of thoughts, questions, or guesses. For example, when Hahn discussed going to a gas station to buy a soda, the therapist was able to approach Hahn with curiosity and ask questions, such as what route Hahn took and what was playing on the radio on his drive there. In addition, the therapist also often used her own mind and experiences in her selection of questions and comments in therapy. For instance, if Hahn mentioned having dinner with his family, the therapist would recall her own family dinners and ask questions about where Hahn sat in relation to his parents and siblings and if Hahn helped set the table or clean up. It should be noted that the therapist did not mention her own experiences in early sessions, as it appeared doing so would be overwhelming or too intrusive for Hahn.

Over time, the therapist was increasingly able to share her own thoughts without derailing the session or Hahn’s agenda. Furthermore, when appropriate, the therapist was able to describe some of her own experiences to help Hahn better reflect on his own and provide more detailed narratives. For example, when Hahn mentioned that he noticed his opinions toward his siblings often shifted but was unable to make sense of this, the therapist shared how she often could feel conflicting emotions toward her sister, depending on how their conversations went. These types of self-disclosing statements often elicited further reflection and details of Hahn’s past experiences. Furthermore, this type of dialogue allowed Hahn to examine the common and dissimilar aspects between his experiences and the experiences of the therapist, which allowed him to better understand the contents of his mind. In addition, the incorporation of this element in therapy allowed Hahn to see the therapist as a unique being with her own thoughts, ideas, and experiences, which served to stimulate his ability to differentiate between others as well as his interest in knowing the thoughts of others.

Element 3 involves eliciting narrative episodes in an effort to gain a better understanding of the patient and his or her life. Rather than gaining a general or abstract idea of a patient’s life, this element encourages the therapist to engage in a mutual exploration of the patient’s experiences, which allows the therapist to picture the unique contexts that make up the patient’s life (21). Exploring the patient’s life stories allows the therapist to better understand the interpersonal dynamics that occur in the session, because patients’ past experiences influence the way they interact and make sense of others. In addition, eliciting narrative episodes helps the patient to begin to reconnect with his or her life story.

Initially, it was challenging to get narratives from Hahn in the session. He always responded to the therapist’s wishes to gain a better understanding of what his life looked like or what certain experiences were like; however, his descriptions of these narratives were often overgeneralized and unclear, such as calling his childhood “good,” “okay,” or “normal.” It appeared that although Hahn was able to recount multiple experiences, including various social roles, achievements, and struggles, his ability to connect to these experiences was limited. These vague narratives that carried little detail made it difficult for the therapist to gain a nuanced understanding of Hahn. In addition, because these narratives often included many long pauses and little detail, the therapist often felt pressure to fill the silence but resisted doing so because this would likely have a negative impact on the therapeutic relationship and would also likely reinforce the practice of the therapist’s filling in the patient’s narrative.

Because it appeared too difficult for Hahn to remember and describe narratives about people or events that were outside the therapy room, the therapist focused on Hahn’s experience in the room. As the therapeutic relationship was able to be narrated, other relationships and events were able to be subsequently described in greater detail (as further described in element 5). Furthermore, when Hahn would begin the session by detailing the tasks he had completed during the week, the therapist would ask clarifying questions about these events, such as whether he went to the grocery store, what he bought, and how much time he spent there. In addition, the therapist would reveal the purpose of asking such questions by making comments such as, “I want to get a picture of what that looked like for you.” It should be noted that the therapist was selective in the interventions she used to elicit narratives in the session and was conscientious to tailor her comments to Hahn’s metacognitive capacities, an essential aspect of MERIT.

Over time, Hahn’s narratives about other relationships and past life events appeared more accessible to him in the session. However, it often appeared that describing these events in the session was akin to searching through fog without a light, because Hahn often had a confused, pained expression on his face when attempting to recall specific details from his past. By asking specific questions about Hahn’s past and the experiences he described, the therapist offered some cognitive scaffolding to help Hahn assemble pieces of his life. In addition, when some aspect of a narrative would present itself, the therapist would be careful to be patient and accept not necessarily knowing all the pieces or how they connected, because integrating all these different fragments of Hahn’s life may have been overwhelming or threatening for him.

After 16 months of therapy, Hahn now appears more comfortable in recalling and bringing up events from his past. He even mentions at the start of some sessions that he has been thinking about past sessions and the narratives that were discussed and shares a desire to explore them further. Although Hahn initially presented to therapy with a paucity of thought, continued focus on narrative episodes, through the application of element 3, has allowed Hahn to reflect on the contents of his mind and engage in goal-directed behavior, which has directly challenged his feelings of apathy toward the world and his environment. In addition, as more fragments from Hahn’s past were made present during the sessions, the therapist was slowly able to connect these pieces to gain a more coherent understanding of Hahn. Through these narratives, the therapist was able to form an image of Hahn as an individual who has often faced isolation, violence, and difficult family interactions, which aided in understanding Hahn as an individual, storied being.

The fourth element of MERIT involves identifying a mutually agreed upon psychological problem that the patient is dealing with. This problem typically emerges as a result of addressing the elements described above. Examples of psychological problems include difficulties understanding others, confusing thoughts, or feelings of personal inadequacy. At the beginning of therapy, Hahn would attempt to identify a psychological problem by regularly mentioning that his “depression was under control” at the start of every session. However, his recitation of his diagnosis appeared parroted, and when asked what that depression felt like or looked like for him, Hahn was able to reply only that he had been taking his medication regularly. Thus, although it may have been tempting for the therapist to consider Hahn’s depression as his psychological problem, it was not expressed in a nuanced or genuine way, which made the therapist consider that it may not be the core problem.

Through mutual exploration of common themes, experiences, and feelings during narratives, as well as through the other elements described above, the therapist and Hahn were able to identify several mutually agreed upon psychological problems that could be discussed in therapy. For example, as Hahn began to view therapy as a place to discuss the contents of his mind, he mentioned having “crazy thoughts” in which he experienced himself having memories but not being sure whether they were true. He stated that when he had these “crazy thoughts,” he felt stuck and often isolated from others. Together, the therapist and Hahn discussed how these thoughts often felt like quicksand pulling Hahn down and keeping him from moving or making sense of his mind. In addition, when Hahn mentioned feeling depressed in later sessions, the therapist and Hahn were able to gain a better understanding of what Hahn’s feelings of depression looked like by comparing them to what Hahn perceived his brother’s experience of depression to be like. For example, Hahn stated that he could tell his brother was depressed when he was “moody and didn’t go to work,” but he stated that he could tell that he himself was depressed when his thoughts felt “heavy” and he stayed in his room all day. Furthermore, as described in element 5, reflecting on Hahn’s apparent discomfort with silence in the session led to the mutual exploration of the difficulty Hahn had in making sense of others’ needs and his feeling of often falling short in the eyes of his family. Through continuous focus on Hahn’s psychological problem by the application of element 4, Hahn’s presentation changed from one of blankness and disinterest to curiosity and growing insight.

Element 5 of MERIT calls for the therapist and patient to jointly identify and explore the interpersonal dynamics of the therapeutic relationship. It was initially quite challenging to reflect on the interpersonal nature of the therapeutic relationship, because Hahn appeared unable to differentiate the therapist from others, such as his past therapist or other clinical professionals he met with. For example, any time Hahn showed up late to a session, he would repeatedly apologize to the therapist, even when the therapist did not mention it or had already stated it was fine. When Hahn continued to repeatedly apologize during a therapy session, the therapist would make comments such as, “I wonder how you expected I would react” or “I wonder what you think about my reaction.” These types of comments encouraged Hahn to consider the therapist as an individual with unique thoughts, feelings, and reactions and allowed for reflection of the interpersonal dynamics in the therapeutic relationship as well Hahn’s hierarchical perception of therapy.

Another challenge concerning this element was Hahn’s tendency to try to please the therapist, particularly toward the beginning of therapy. When the therapist would ask Hahn questions regarding his perceptions or experience of therapy, he would consistently respond in the positive, stating that the session was “good” or “helpful.” The therapist would gently challenge Hahn by commenting, “I wonder if you would tell me if it was not going good” or “I wonder what it would look like if this session was not helpful.” These types of comments encouraged Hahn to reflect on the content of the sessions and on his perceptions of the interpersonal dynamics that were present. In addition, the therapist hoped that focusing on these interpersonal processes and the parts of therapy Hahn did not find as helpful would promote a non-hierarchical therapeutic relationship, a key aspect of MERIT.

As stated previously, Hahn often appeared uncomfortable during silences in the session. If the conversation lagged, he would almost immediately start reciting his list of weekly tasks or assure the therapist that he was doing “good” and taking his medicine. The therapist reflected on this pattern in their relationship and encouraged Hahn to wonder what would happen if he did not fill silence. Hahn responded that he would become “awkward and uncomfortable.” This led to an exploration of other times in Hahn’s life when he experienced feeling awkward and uncomfortable. In addition, the therapist shared the feelings of nervousness she felt in those periods of silence and the urge she experienced to fill these silences. Revealing her vulnerabilities in this way encouraged the mutual exploration of an interpersonal process occurring in therapy and allowed the therapist to promote a nonexpert stance, an integral aspect of MERIT. Moreover, the application of element 5, which calls for continued focus on interpersonal processes in the session, challenged Hahn’s lethargic and apathetic position toward others. Hahn appeared more interested in his interactions with others, such as members of his family, and brought up these moments in the session. Further joint discussion regarding Hahn’s fear of silences led him to reveal his worry that if he became quiet in the session and let the silence linger for too long, his mind would “go blank in session and not wake up again” and this reflection led to another psychological problem.

The sixth element of MERIT calls for the therapist and patient to notice and reflect on the mental activities occurring within the session. The therapist asks questions such as, “How did today go for you?” or “What stood out to you today?” This invites the patient to think about what occurred during the session with the therapist. As stated previously, Hahn often appeared as if he wanted to please the therapist; thus, when asked how the session went, he would often appear uncomfortable and always answer in the affirmative, describing the session as “good” or “fine.” Over time, the therapist encouraged Hahn to expand on these answers by asking questions such as, “What part of today was good?” or “What would it look like if this was a bad session?” Eventually, Hahn began to find it less unnerving to be asked these questions, and when asked how the session went, he described what parts of the session stood out to him.

In addition, as the therapist and Hahn continued to reflect on what was occurring throughout sessions, he was able to notice how his thoughts changed from the beginning to the end of the session. For example, he described how on the drive to the therapist’s office and during the beginning of the session, his thoughts often felt “cloudy” and difficult to grasp; however, as the session progressed, his head felt “clearer” and it was easier to identify his thoughts. He once mentioned how he often felt more “confident” at the end of a therapy session because his “thoughts made more sense.” In addition, reflecting on element 6 of MERIT allowed for joint discussion regarding the changes in Hahn’s original presentation as lethargic and anhedonic to more expressive and engaged. For example, when exploring a past therapy session, Hahn once mentioned how “quiet” he used to be and how he now found it “much easier to talk and think.”

The seventh element or MERIT calls for the therapist to utilize interventions that stimulate patients to engage in increasingly complex acts of self-reflection or reflections about others. It is essential that the therapist offer interventions that are tailored to the patient’s level of self-reflectivity, which is measured by the MAS-A. Hahn began therapy with fairly low levels of self-reflectivity. Although he was able to recognize that he had his own thoughts and could identify some cognitive operations, such as “thinking” and “remembering,” he was unable to identify a variety of internal states. In addition, he struggled to identify and describe his emotional experiences. When describing narratives that seemed to provoke some level of personal distress, Hahn often used words such as “weird” or “hard.” Thus, the therapist initially offered interventions that commented on Hahn’s recognition of mental operations. In addition, during certain descriptions of narratives, Hahn was sometimes unable to describe the cognitive operations he experienced during a specific narrative. The therapist then offered reflections, such as, “You remember watching television, but you don’t remember what you watched. I wonder if that surprises you?” These sorts of reflections allowed the therapist and Hahn to focus on the mental states he experienced and broadened his experience of cognitive operations to using words such as “wished,” “hoped,” and “believed.”

In regard to the recognition of emotional states, as Hahn was able to identify a wider range of cognitive operations, the therapist encouraged greater self-reflectivity by offering reflections of the emotions Hahn appeared to be describing as he discussed certain narrative episodes. However, the therapist had to be cautious in offering guesses about Hahn’s emotional states, because Hahn had a tendency to want to please the therapist and often agreed with whatever emotion the therapist suggested. When Hahn struggled to make sense of his emotional state, the therapist asked him to consider what he felt in his body when he described certain experiences. For example, Hahn described a narrative episode in which he experienced significant anxiety as a child before his first softball game. However, when describing this experience, Hahn initially used vague emotional descriptors such as “hard.” The therapist encouraged Hahn to consider what physical sensations he experienced when describing this narrative, and he described his inner state as “shaky” and “fast.” The therapist reflected that she often felt “shaky” and felt her heart was beating very “fast” when she was nervous and wondered whether it was possible that Hahn felt nervous before his first softball game. Hahn agreed and was able to use other words, such as “scared” and “anxious,” to describe his emotional state during this narrative. Over time, Hahn started to use a range of nuanced emotions with little scaffolding from the therapist.

As therapy progressed, Hahn began to display some instances of the next level of self-reflectivity: fallibility in thinking, which refers to the ability to notice that one’s thoughts can change and to view thoughts as subjective versus absolute. Hahn displayed fallibility in thinking in that he was able to recognize his thoughts changing during the course of a session. For example, in one therapy session, he shared that he felt nervous when describing a certain narrative episode that he experienced when he was a child, but toward the end of the session, he stated he felt “confident” that he was able to voice his concerns. The therapist encouraged Hahn’s recognition of his changing mental states by offering reflections such as, “You were nervous when you came in, but you noticed that after you shared this memory, you’re feeling differently. You’re feeling confident.” Hahn also demonstrated some capacity at the sixth level of self-reflection: patients can recognize that what they think, hope, and want may not match up with what is realistically possible in their lives. For example, as Hahn described a number of narrative episodes from his childhood and young adulthood, he was able to describe the sense of disappointment he experienced that things had not turned out the way he had planned and that the life he currently led was different from what he had imagined when he left the military.

In regard to awareness of others’ minds, Hahn was able to recognize that others have their own thoughts, but he was unable to identify the range of cognitive operations that other people experience. Hahn had difficulty differentiating people in his life and appeared to see his current and former providers in one hazy mass. For example, when Hahn’s current therapist asked Hahn what was different between her and Hahn’s previous therapist, Hahn responded, “She used a tape-recorder and you don’t.” Thus, the therapist attempted to introduce her mind into the session to help Hahn recognize the therapist as a person with unique thoughts and ideas. In addition, when Hahn described narrative episodes involving others, the therapist would encourage him to consider what the individuals in his accounts were thinking or feeling. For example, Hahn once described that he did not talk to his brother the day before because his brother was “moody.” The therapist asked Hahn to consider how he could tell that his brother was “moody.” As Hahn’s ability to recognize and identify the unique thoughts and feelings of others progressed, he was able to construct increasingly complex representations of others in his mind, such as when he was able to describe his experience of sadness versus his brother’s experience of sadness. As mentioned above, Hahn originally presented with paucity of thought and avolition. Through the implementation of this element, which promotes continued focus on the contents of the patient’s mind and the minds of others, Hahn began to identify a range of subjective experiences and expressed interest in the world around him.

The eighth element of MERIT calls for the therapist to stimulate the patient’s ability to use knowledge about oneself or others to respond to psychological problems as well as challenges and obstacles that occur in daily life. This does not call for the therapist to engage the patient in goal-directed activity but rather encourages patients to recognize themselves as agents who can utilize their understanding of self and others to cope with psychological problems that are a source of distress. As mentioned above, Hahn initially offered vague ideas of his psychological problem in reciting the diagnoses he had been given, without explaining his connection to these diagnoses or descriptions of his experiences with their symptoms. For example, toward the beginning of therapy, Hahn often began the session by reporting the status of his depression, describing it as “under control” or “bad,” and explaining that he was managing it by taking his medicine as prescribed. However, through exploring a number of narrative episodes, Hahn and the therapist were able to discuss what “depression” actually looked like for Hahn and how he responded to his feelings of sadness and anxiety that resulted from being around others by isolating himself and staying in his room for days. In addition, Hahn began to actively elicit the therapist’s thoughts about certain feelings he was struggling with, such as the loneliness he experienced when he recognized that many of the people he once knew and had relationships with were no longer around. Hahn also noted that he began to seek out the support of his family members when he was feeling “upset” or experiencing feelings of sadness. Thus, the use of this element, which stimulated Hahn’s understanding of his psychological problem as well as his ability to respond to these identified challenges, allowed him to take on the role of an active agent in his life versus the passive position he originally held.