Metacognitive Reflection and Insight Therapy for Schizophrenia: Case Study of a Patient With a Co-Occurring Substance Use Disorder
Publication: American Journal of Psychotherapy
Abstract
Decrements in metacognitive functioning, or the ability to form complex and integrated representations of oneself and others, have been identified as a core feature of schizophrenia. These deficits have been observed to be largely independent of the severity of psychopathology and neurocognitive functioning and are linked to poor outcomes for those with the disorder. This study is a case illustration of the efficacy of metacognitive reflection and insight therapy (MERIT) in increasing the metacognitive capacity of an individual diagnosed as having co-occurring schizophrenia and a substance use disorder during three years of individual therapy. The eight elements of MERIT, which promote metacognitive growth, are presented as they apply to the present case. Case conceptualization, outcomes, and prognosis are also presented. These eight elements enabled the patient to move from a state of gross disorganization—unable to identify his thoughts or present them in a linear fashion—to one in which he was able to develop increasingly complex ideas about himself and others and integrate this understanding into a richer sense of himself, of his psychological challenges, and of the role that substance use played in his life. Results of the study also illustrate the foundational necessity of self-reflectivity in order to facilitate understanding of the mind of others and the relationship between psychological pain and the emergence of disorganization.
Metacognition refers to a spectrum of mental activities that range from discrete acts, such as thinking about one’s own thinking or contemplating the mental activity of others, to an increasingly more complex synthesis of these abilities into an integrated sense of oneself and others (1, 2). The absence of these abilities results in difficulties with appropriately responding to psychosocial challenges and, therefore, hinders recovery. Although some researchers consider metacognition to be a component of social cognition (3), metacognition differs from social cognition in that it is not concerned with the accuracy of one’s emotional or social judgments. Instead, it focuses on how this information is integrated into a more complex understanding of oneself and others. This distinction between social cognition and metacognition as conceptually different factors has been illustrated in previous studies using principal-components analyses (4).
Deficits in metacognitive capacity among those with schizophrenia have been recognized and observed for more than two decades and are considered to be a stable and key feature that underlies symptoms of the disorder (5). Intact metacognitive functioning has been found to be associated with psychosocial outcomes, including higher work performance (6) and intrinsic motivation and learning (7). Decrements in metacognitive function, in contrast, have been linked to poorer functioning and outcomes (8). Although metacognition is correlated with severity of psychopathology, previous research suggests that deficits in metacognition cannot solely be explained as reflections of symptoms or features of the disorder (9, 10).
Given the identification of metacognitive deficits as a core feature of schizophrenia spectrum disorders, novel interventions that target rebuilding atrophied metacognitive capacities are of paramount importance (11). One such integrative intervention is metacognitive reflection and insight therapy (MERIT) (12). MERIT is an integrative treatment that seeks to promote synthetic metacognitive capacity and was developed to target deficits in the four elements of metacognition among individuals with psychotic disorders.
Although MERIT is a manual-based intervention, it does not follow a prescribed treatment protocol. It is instead a flexible and target-driven approach whereby therapists and patients think together, and patients are encouraged to reflect on their ideas of themselves and others. Metacognitive ability is operationalized as a hierarchical capacity within MERIT, with each level of functioning building on the abilities needed for the previous level. As such, interventions within this framework should be tailored to the patient’s current metacognitive capacity and aim to facilitate metacognitive growth toward increasingly complex and integrative metacognitive acts.
MERIT consists of eight interrelated therapeutic elements that should be present in each session. These include attending to the client’s agenda, including the therapist’s thoughts as part of a dialogue, eliciting narrative episodes, defining a psychological problem, discussing interpersonal processes within the session, evaluating progress, stimulating reflective acts about oneself and others, and stimulating the use of knowledge about oneself and others to respond to psychological problems. These elements are each discussed below in the context of the case presented.
Several previous case studies (13–15) have demonstrated the efficacy of MERIT in assisting individuals with schizophrenia with forming more complex ideas about their own mental states and the mental states of others. In addition, MERIT has been shown to help individuals synthesize that information into an integrated sense of themselves and others. These case studies have evaluated patients in both early and later phases of their illness and have included individuals with a range of clinical presentations.
One limitation of the case work to date is a lack of inclusion of clinical cases of individuals presenting with co-occurring substance use disorders. Epidemiological data have shown that approximately 40% to 50% of individuals with schizophrenia also have a substance use disorder (16). Moreover, substance use disorders among this population are associated with poor outcomes, including poor response to treatment, hospitalization, suicide, and homelessness (17).
It, therefore, seems especially important to consider this group, given that integrative psychotherapy interventions may reduce the risk of these poor outcomes. People with schizophrenia and co-occurring substance use disorder also appear to possess low levels of metacognition and lower levels of metacognitive mastery, which enables individuals to identify a psychological problem and use their knowledge about themselves to appropriately respond to that problem. Therefore, the current article presents a comprehensive case study of the application of MERIT in the treatment of an individual diagnosed as having co-occurring schizophrenia and substance use disorder.
Case Illustration
Presenting Problem and Client Description
We refer to the client for this case as Dylan. We have modified details of this case report, such as name and other identifying information, to protect his confidentiality while preserving the illustrative value of the case. Dylan was a Caucasian man in his late 40s who lived in a rural midwestern town with his older brother. He was single and had never married, and he did not have any children.
Dylan’s parents divorced when he was four years old, and he was the youngest of three children. At the time of this therapy, his mother and brother lived in the same state as Dylan, and his father lived in a neighboring state. His eldest brother died approximately 10 years prior from a drug overdose. It was not clear whether there was a history of schizophrenia in Dylan’s family; however, he described instances of his mother’s disorganized behavior, including examples of times when she apparently shouted at someone who was not there and other occasions when she discussed her unusual beliefs with Dylan. He also endorsed a family history significant for alcoholism.
Dylan described a chaotic and conflict-ridden household prior to his parents’ divorce; his father was often drunk and volatile, and his parents frequently fought. After his parents’ divorce, Dylan and his older siblings were raised by his mother. He described a nomadic childhood characterized by poor living conditions. He and his siblings moved to a new home every few years, first moving within the state and then ultimately settling in the southeastern United States.
Largely absent during his childhood and young adulthood were close connections with others, both outside the family (as a result of his frequent moves) as well as within the family in his relationships with his siblings and mother. At the age of 16, frustrated by his mother’s increasingly erratic and disorganized behavior, Dylan decided to hitchhike back home to the Midwest, where he completed high school while living with his uncle. After high school, he worked odd jobs at home before joining the military.
Dylan was diagnosed with schizophrenia in his early 20s, two years into his military career and in the wake of a recent rejection by a woman he was dating. Dylan reported that at this time his drinking and social isolation significantly increased. He was admitted to the hospital by his commander after displaying strange and disorganized behavior and speech, and he remained in the hospital for approximately six months, after which he was discharged from the military.
After his discharge, Dylan moved back to the Midwest to live with his mother in an environment similar to that of his nomadic formative years. During this time, Dylan’s drinking continued to escalate, which he attributed to the stress of living with his mother. His drinking culminated in a citation for driving under the influence of alcohol and a short jail stay, during which his disorganized behavior also briefly intensified.
Ultimately, Dylan chose to move back to his home state to live with his brother, first in a series of trailer homes and later in a home Dylan purchased in a rural town. Over the next several years, his drinking persisted. Coupled with his limited insight and difficulties connecting with others, his alcohol use led Dylan to surround himself with and take in as roommates people who also abused substances. This pattern of behavior ultimately led to a drug-related arrest two years prior to the start of psychotherapy with this provider (AJ).
At the start of psychotherapy, Dylan had been clinically stable with his medication-management regimen for several years. He was serving probation for his drug charge, for which he was required to participate in group psychotherapy and 12-step programming. Prior to psychotherapy with this provider, Dylan had previously participated in individual therapy for a period of one year, but he demonstrated limited engagement in the therapeutic relationship and his treatment.
When Dylan started therapy, he demonstrated significant disorganization of his thoughts and speech and possessed a fragmented account of the narrative events of his psychosocial history. He described hearing voices and seeing strange figures, and he possessed vague delusional beliefs about the government and religion. Dylan also presented with profoundly flat affect, and his sporadic emotional expressions were frequently incongruent with the subject matter being discussed. With regard to his substance use, he demonstrated some awareness that his past drug and alcohol use had caused problems for him, but he lacked an understanding of the factors precipitating his use. Similarly, Dylan’s descriptions of past use contained images of himself as a passive recipient of drugs and alcohol, devoid of any agency or volitional accounts of his use.
Case Formulation
We conceptualized Dylan’s psychosocial difficulties as resulting from low metacognitive capacity, and we therefore used the Metacognition Assessment Scale–Abbreviated (MAS-A) (18) to illustrate these deficits. The MAS-A is an adaptation of the Metacognition Assessment Scale, which was originally created by Semerari and colleagues (2) to assess metacognitive function during psychotherapy. The abbreviated version was modified to allow for the assessment of metacognition in personal narratives and was created in conjunction with the original authors.
The MAS-A is subdivided into four scales, each of which measures a separate facet of metacognition. These four subscales include self-reflectivity, or the ability to identify and ultimately integrate information regarding one’s own internal states; understanding the mind of the other, or one’s ability to identify and synthesize information with regard to the mental states of others; decentration, or the capacity to recognize and consider the unique perspective of others; and mastery, or one’s ability to identify a valid psychological problem and use knowledge of oneself to decrease psychological distress. Higher scores on each of the four subscales are reflective of higher metacognitive capacity, whereby individuals are able to form and then synthesize complex representations of themselves and others.
Regarding self-reflectivity, at the onset of psychotherapy Dylan was able to recognize that his thoughts were his own, but he was unable to recognize and differentiate among a variety of cognitive operations aside from his thoughts and memories. Similarly, Dylan was unable identify or distinguish among his emotional states or integrate how his thoughts or feelings might affect his actions, such as his substance use. During these initial stages of treatment, Dylan’s thoughts were often disorganized, resulting in nonlinear and often confusing narratives interjected with delusional thinking and abstractions.
In terms of understanding the mind of the other, Dylan was initially capable of only the most fundamental interpersonal reflections. At a basic level, Dylan was able to recognize the existence of mental functions within the other, but he was unable to distinguish among mental states or identify emotional states within other people. Regarding decentration, Dylan was initially unable to see things from multiple perspectives or differentiate others’ experiences from his own. Thus, he did not possess the capacity to understand that others might possess differing opinions or perceive events differently than he did.
Last, in terms of mastery, at the onset of therapy Dylan was unable to articulate a psychological problem in a nuanced way. Although he was able to acknowledge himself as having a mental illness and recognize a desire to “stay out of trouble” (given that he was on probation at the time), Dylan was unable to articulate more specifically what this meant to him. As a result, his psychological problem appeared to be more a reflection of something he was socialized to report.
Course of Treatment
Element 1: the preeminent role of the client’s agenda.
This first element of MERIT focuses on what the client wants during each therapy session. It is important to note that a client may present with differing agendas in each session, may present with several different agendas simultaneously, or may even be unaware of some or all of the agendas he or she brings to session. Awareness of and attendance to agendas both known and unknown by the client are of paramount importance in the context of the therapeutic relationship.
At first, it was difficult for the therapist to deduce what Dylan wanted out of therapy. In their initial sessions, Dylan described a general desire to “stay out of trouble,” but he was unable to explain in any detail what this meant to him. Given that Dylan was on probation as a result of a recent drug arrest at this time, it was unclear to the therapist whether Dylan attended their sessions for any reason other than meeting his probation requirements for weekly contacts with a mental health provider.
Although seemingly unrelated, it is also of note that during these first several sessions, Dylan presented to therapy with various objects for what he called “show and tell.” These items largely consisted of kitschy household knickknacks, many of which were acquired from garage sales or passed on unceremoniously to Dylan by acquaintances. Although he expressed a desire to share these items with the therapist, the narrative details of the events surrounding his acquisition of the items quickly revealed a lack of emotional attachment to the items. Given this behavior, Dylan’s apparent lack of psychological distress, and his disorganized thought processes during these initial sessions, the therapist had to be willing to endure the uncertainty and discomfort associated with her desire to make sense of his experiences and understand Dylan’s agenda. Thus, she accepted his agenda as unclear and framed it as something they could mutually explore to later establish his psychological problem and clarify the goals of treatment.
With time, the therapist noticed that Dylan’s disorganization often arose at specific times, such as after discussion of difficult interpersonal interactions or losses, or toward the end of sessions spent integrating these interactions throughout his life. For example, in the wake of discussing a narrative about the loss of his brother during one session, Dylan’s thought processes became increasingly more disorganized, and he began to explain his delusional ideas about the role a government conspiracy played in his loss. Dylan also became notably more disorganized for a few sessions at the end of therapy, during which the therapist and Dylan processed the upcoming termination of their work together.
Similarly, with time the therapist also noticed that Dylan’s pattern of substance use primarily occurred within interpersonal contexts. His use was often spurred by attempts at or failed connections with others, or an apparent desire to elicit caring or concern from his therapist. For example, on one occasion after a sustained period of sobriety, Dylan relapsed with a new acquaintance during the therapist’s extended vacation.
The therapist’s observation of Dylan’s disorganization ultimately led her to form the idea that his disorganization served to protect him from the distress caused by his conflicts or lost connection with others. This understanding afforded her a framework for understanding other behaviors, such as Dylan’s “show and tell” and his pattern of substance use, as attempts to connect with others. Thus, the therapist’s understanding of Dylan’s agenda came to be that his objective was to connect with others, but that this effort was impeded by his low abilities to reflect on the minds of others and view others as distinct individuals with lives independent of his own.
Element 2: introduction of the therapist’s thoughts in ongoing dialogue.
This second element involves discussion of the therapist’s thoughts during therapy in a manner that facilitates an open dialogue between client and therapist. Accomplishment of this element requires that the therapist disclose the contents of his or her mind while also encouraging joint reflection about these thoughts. This reflection on the thoughts of the therapist aids in stimulating the client’s metacognitive capacity to understand the mind of the other. It also increases clients’ self-reflectivity as they explore their own reactions to the mental content of the therapist.
During the early stages of therapy, Dylan frequently presented as disorganized and tangential in session and was unable to recognize his own mental activities or those of others. As a result, the therapist was often confused and left therapy sessions frustrated and exhausted from the strain of attempting to follow Dylan’s train of thought. To address this issue, the therapist inserted her own thoughts during sessions to establish her mind as independent from Dylan’s and to reflect her feelings of confusion. She offered comments such as, “I’m confused; help me understand what made you think of that just now,” or, “I’ve noticed that when you have many thoughts in your head, I find myself confused.” These remarks assisted in scaffolding Dylan’s ability to reflect on his own thinking, which ultimately led to more linear and sequential thought processes.
At later stages in therapy, the therapist offered relatively more complex and integrated reflections to increase the salience of the relationship among Dylan’s substance use, emotions, and interpersonal interactions. For example, she offered comments such as, “I notice that you usually drink only when you’re around others. I wonder if that is because it’s harder to get along with others when you’re sober?” or, “When I was away, you chose to use. I’m wondering what I should make of that?” Dylan was invited to reflect on the thoughts of the therapist and whether he agreed with her interpretations. These reflections helped Dylan to differentiate his thoughts from those of the therapist while also laying the groundwork for establishing a shared sense of his psychological problem.
Element 3: the narrative episode.
The third element of MERIT emphasizes eliciting narrative episodes from the client to facilitate construction of a storied sense of the client’s life events. This eliciting of narrative episodes enables a shared sense by therapist and client of the client over time. In addition, it aids the therapist’s conceptualization of the client as a unique and complex being, rather than as merely a compilation of his or her symptoms.
At the start of therapy, Dylan lacked a storied sense of his life, and, as a result, this was a difficult task to engage in. His thought processes vacillated from barren to disorganized, both between as well as within sessions. He was often unable to temporally anchor when events in his life occurred, and he provided vague overviews of interactions and events. For example, Dylan was unable to identify how old he was or where he was living when a given event occurred. This inability to construct a linear narrative was difficult for the therapist as well, because she had to endure barrages of Dylan’s disorganized thoughts. As a result, she also struggled against feelings of confusion and frustration that arose out of her desire to force integration on Dylan’s life and thoughts.
To stimulate narrative episodes, the therapist inquired about whether there were other times in Dylan’s life when a similar event, thought, or feeling occurred or, conversely, whether there had been times when things were different than the event being described. To elicit narrative details when Dylan provided narratives that were barren, the therapist made numerous specific inquiries about the event (e.g., “How old were you when this happened?” or “Where were you living?”) in an effort to model the level of detail necessary for her to formulate a picture in her mind of the event. When Dylan provided disorganized narratives, the therapist intervened without judgment or correction, with questions aimed at eliciting linear thought, such as, “We were just talking about your mom, and now we’re suddenly talking about your car. Did you notice that, too?”
The therapist also maintained a similarly nonjudgmental and nondirective approach while obtaining narrative details about Dylan’s substance use. In gathering these narrative details, the therapist sought to better understand the context in which Dylan used through questions such as, “Who else was there?” “What time of day was it?” or “What were the thoughts in your mind just before using?”
Over time, Dylan began to provide richer and more detailed narrative episodes and started to self-monitor the tangential shifts in his narratives. He also became better able to reflect on the potential internal catalysts to his use of substances (e.g., “Maybe I was bored?”), which afforded a first step in the establishment of Dylan as an active agent in his decisions and life. As Dylan provided more narrative episodes, the therapist was also able to establish a timeline of his life events, which enabled the therapist and Dylan to possess a joint understanding of his life over time as well as the relationship among these events. Themes of isolation, interpersonal conflict, and loneliness arose from narratives describing his frequent and abrupt moves as a child, the end of his only significant romantic relationship, alcohol and drug use throughout his adult life, and his pattern of taking in people in need as roommates. These themes aided in the conceptualization of Dylan’s psychological problem, which is discussed in more detail below.
Element 4: the psychological problem.
The fourth element to be attended to during therapy is the formulation of a psychological problem. To achieve this element, the client and therapist must jointly identify and agree on a valid and plausible psychological problem. Examples of psychological problems that may manifest in treatment include feelings of loneliness stemming from difficulties in connecting with others, interpersonal conflict resulting from a lack of understanding of the mind of others, and feelings of anger and resentment stemming from past events.
During the early stages of therapy, Dylan was unable to clearly articulate a psychological problem. He expressed a desire to “stay out of trouble” but was unable to describe in any nuanced detail what he meant by that statement. It was clear to the therapist that these utterances were largely related to his recent drug-related arrest with a former friend and were likely parroted from his 12-step program or his interactions with his probation officer.
As therapy progressed and Dylan offered more personal narratives, he began to share narratives with themes of his struggles to connect with others and difficulties in understanding the mental states of others and judging their intentions. He described an unstable childhood with frequent moves, which made it difficult for him to form and maintain relationships; a past confusing and abrupt break-up with a former girlfriend; and his more recent behavior of taking in as roommates people who later became problematic and took advantage of Dylan.
At this point, Dylan’s psychological problem became more clearly defined, given that many of his attempts for connection were thwarted by his difficulties in understanding others. This understanding of Dylan’s psychological problem as a difficulty in connecting with others also afforded the therapist a framework for conceptualizing his actions. For example, his substance use with others provided Dylan with a shared experience that he lacked while sober. Similarly, his attendance at 12-step meetings enabled Dylan to establish relationships with individuals who were also stigmatized as part of an “outgroup.”
This development of Dylan’s psychological problem was achieved throughout the processes defined in the first three elements of MERIT. Dylan began to come to his therapy sessions with a purpose, discuss narrative episodes from his life with the therapist, and reflect on her reactions to the events he shared. Through these processes, Dylan was ultimately able to begin to self-reflect about himself and his experiences in a more complex and integrated way.
Elements 5: reflecting on interpersonal processes within the session.
The fifth element of MERIT necessitates that the therapist call attention to the interpersonal dynamics between the client and therapist as they occur within the therapy session. This process was initially a difficult task for Dylan at the start of therapy, given his inability to recognize the therapist as possessing a life largely independent of his own. Moreover, it was compounded by his low levels of self-reflectivity and understanding of the mind of others. To address this in her initial interventions, the therapist focused on helping to cultivate Dylan’s capacity for reflecting on his thinking. The therapist also offered reflections about her own mental activity and offered relevant self-disclosures in an effort to scaffold Dylan’s decentration.
As time passed, the therapist began to note dynamics between herself and Dylan as they arose in sessions. She also encouraged Dylan to reflect on his ideas about the therapist. For example, in several sessions throughout the course of therapy, Dylan disclosed his relapses with drugs and alcohol to the therapist. Early on, the therapist was cognizant that her responses to Dylan’s relapses were often simultaneous feelings of disappointment and concern as well as a desire to control the potential for future relapses. In lieu of engaging Dylan in a skills-based discussion of identifying coping strategies or other safeguards for his substance use, she instead inquired about what Dylan was seeking from her by sharing the information (e.g., comfort and caring, alarm and shock) and disclosed to him how she felt compelled to react.
Discussions such as these laid the groundwork for deeper future explorations of the therapeutic relationship and the ways both Dylan and the therapist were affected by one another. This element was perhaps most salient during the end stages of therapy, during which Dylan and the therapist together reflected on the changes and growth that were facilitated by the therapeutic relationship over the course of therapy.
Element 6: reflecting on the process of therapy within the session.
The sixth element of MERIT requires that the therapist facilitate discussions about the therapy process within sessions as well as the process as a whole. The successful application of this element establishes therapy as an active experience in which reflection is encouraged. Initially, Dylan tended to respond to the therapist’s inquiries about how a given session went with brief positive replies (e.g., “It was good”) but was unable to elaborate more fully regarding the specific elements that made the experience positive for him. As therapy progressed, Dylan began to offer more detailed reflections about the sessions and became better able to differentiate elements that were similar or dissimilar to their other sessions.
As his ability to reflect on his cognitive operations improved, his responses to the therapist’s inquiries began to reflect an increased understanding of himself and their sessions over time. This increased understanding was evidenced by statements such as, “I jumped around more in our discussion today,” or “I think I confused you more today.” Such insights show that Dylan was able to identify periods of increased thought disorganization and how this disorganization affected the processes within the session.
Element 7: stimulating self-reflectivity and awareness of the other’s mind.
The seventh element calls for the therapist’s ongoing assessment of the client’s ability to reflect on the mental states of the self and others. The therapist assesses both self-reflectivity and awareness of the other’s mind using the MAS-A. The therapist then tailors psychosocial interventions during sessions in accordance with the client’s metacognitive capacity in each domain. He or she also provides scaffolding to facilitate metacognitive growth to higher and more complex levels of reflectivity.
At the start of therapy, Dylan presented with low levels of self-reflectivity. He was unable to distinguish different kinds of cognitive operations or recognize and name nuanced emotions in himself. As a result, Dylan was unable to reflect on the link between his mental activity and behaviors, such as substance use. For example, Dylan recalled events from his life during sessions but appeared to be unable to recognize himself as experiencing a memory while recounting the event.
Similarly, he appeared to lack awareness of his own thoughts and how one of his thoughts might create or lead to a new thought. This lack of awareness was especially apparent during times of increased thought disorganization. At times Dylan reported an emotional experience, such as feeling “stressed,” but he was unable to recognize a variety of nuanced emotions.
As a result, the therapist initially did not explicitly address Dylan’s substance use, which necessitated advanced levels of metacognition so that he could identify his thoughts and feelings and reflect on how they might be affected by interpersonal or situational factors. Instead, the therapist’s initial interventions centered on increasing Dylan’s ability to recognize a variety of his own mental operations and reflecting on his mental content as it manifested during sessions. For example, the therapist offered reflections such as, “Your thoughts are confused,” or, “You’re remembering your mother.” The therapist also assisted Dylan through modeling, by offering narrations of her own mental processes such as, “I’m curious…I think…I remember….”
As therapy progressed and Dylan became better able to reflect on his mental activity, the therapist tailored her interventions to target higher levels of self-reflectivity. She encouraged Dylan’s exploration of his emotions by inquiring about the physical sensations in his body and then linking those sensations to an emotional experience: “You said that you felt butterflies in your stomach…I wonder if that was anxiety you were feeling?” The therapist also offered her reflections on how she might feel in similar situations (e.g., “If that happened to me, I would expect that I might feel sad”).
Later interventions focused on identifying and highlighting how Dylan had changed over time and then how reality had unfolded independently from Dylan’s hopes and expectations. To accomplish these goals, the therapist offered reflections aimed at emphasizing these elements as they occurred naturally in Dylan’s narratives (e.g., “You used to think… but now you see things differently”) and offering questions intended to parse Dylan’s expectations and sense of himself over time (e.g., “Were you surprised about how things worked out with your roommate?”).
By the conclusion of therapy, Dylan was at the beginning stages of his ability to integrate how his actions were affected by his thoughts, feelings, and interactions with others within discrete narrative episodes. With this increased capacity for self-reflection, Dylan was able to begin to reflect on the factors that precipitated his substance use. To facilitate this reflection, the therapist began to offer her interpretations to Dylan, such as, “I’m wondering if you drank on Saturday because you were sad and lonely?”
With regard to reflectivity of the mind of the other, Dylan initially possessed low levels of understanding of the minds of others. Although he was able to recognize that others experience thoughts of their own, Dylan could not identify multiple different cognitive operations in the minds of others. The therapist offered similar interventions to those described above for targeting self-reflectivity, including sharing her own mental activity in sessions with Dylan. Toward the middle of their work together, Dylan progressed from identifying a variety of cognitive operations in the minds of others to noticing their emotions (e.g., the anger of a fellow group member, concern and empathy from his therapist).
By the conclusion of their work, Dylan began to demonstrate the next level of understanding of the mind of others on the MAS-A: the ability to make inferences about mental activity of others. This level of metacognitive functioning was evidenced in his ability to recognize the therapist’s facial expression and then use that information to make a hypothesis about her mental activity. For example, at this stage Dylan was able to identify a perplexed expression on the therapist’s face and would then state, “It looks like you have a question.”
Element 8: stimulating mastery.
The eighth and final element of MERIT requires that the therapist help stimulate the client’s utilization of knowledge about him- or herself and others to identify and subsequently respond to a psychological problem. As mentioned above, at the beginning of therapy Dylan was unable to clearly define a psychological problem, reporting a desire to “stay out of trouble” and “not relapse” in the wake of his recent arrest and probation. However, Dylan was unable to further articulate what staying out of trouble might look like or why it was important to him, which left the therapist the impression that this goal was more a reflection of what was expected of Dylan by his probation officer or by those from his 12-step meetings. Additionally, it was unclear to the therapist whether Dylan’s substance use was truly a source of distress to him or whether it was instead a manifestation of more deeply rooted difficulties in forming and maintaining relationships with others that resulted from of his low metacognitive capacity.
During the initial stages of treatment, the therapist’s interventions centered on gathering narrative details of the events surrounding Dylan’s substance use while also eliciting narratives of past moments of distress. As she elicited these narratives, it became clear to the therapist that Dylan’s substance use occurred almost exclusively within the context of social situations in which he was offered drugs or alcohol by his acquaintances. The narratives also revealed Dylan’s past unsuccessful attempts to connect with others and the shared sense of purpose and “otherness” derived from his attendance at meetings or in groups.
Later during treatment, Dylan became increasingly able to articulate his psychological problem of difficulty in understanding and connecting with others. It became clear to the therapist that Dylan’s substance use was largely precipitated by his difficulties in understanding others and his attempts at connection. He progressed from using unhealthy strategies, such as his substance use, to connect with others to more adaptive approaches, such as using the therapist as a support to address other aspects of his presentation (e.g., thought disorganization) that made connecting with others difficult. Overall, the therapist’s interventions assisted Dylan with developing a more nuanced understanding of his psychological problem while also aiding him in considering strategies to address it.
Absent from this element of MERIT was a prescriptive or directive approach whereby the therapist informed Dylan of what his psychological problem was or focused on demanding sobriety of Dylan. Instead, the therapist worked to gain a deeper understanding of the distress Dylan experienced and the underlying function that substance use played in his life. This deeper understanding assisted in providing a context for his experiences and enabled Dylan to better define his psychological problem.
Outcome and Prognosis
When Dylan first began participating in MERIT, he presented with low metacognitive capacities. He was aware that he possessed thoughts, but he was unable to recognize a variety of cognitive operations; identify his emotional experiences; or recognize the interplay among his thoughts, feelings, and actions. Dylan also had difficulty with recognizing these experiences in others and differentiating the experiences of others as separate and unrelated to his own. At the start of treatment, he also a lacked a coherent account of his psychosocial problems, an understanding of the role his substance use played in these problems, and strategies for coping with his psychosocial challenges. Through the application of each of the eight elements of MERIT, Dylan dramatically improved his capacity for metacognition.
By the termination of treatment with his therapist, Dylan was able to form more complex and integrated ideas about himself and others in the context of specific events from his life. He developed the ability to recognize his emotional experiences, fallibility in his thinking, and changes in his thinking over time. Toward the end of treatment, Dylan also was increasingly able to reflect, with scaffolding from the therapist, about how his interactions with others affected his thoughts and emotions and to consider the relationship between these experiences and his substance use.
One could argue that Dylan’s most striking metacognitive gains occurred in his ability to understand the minds of others and view them as independent from himself. At the end of treatment, he was able to recognize a variety of cognitive operations in the minds of others, identify their emotions, and make reasonable conjectures regarding the mental activity of the therapist in response to her facial expressions (e.g., “It looks like you have a question”). Last, Dylan had made steps toward identifying his psychological problem of difficulty with connecting with others.
By the end of therapy, Dylan had less severe positive symptoms, and the frequency and severity of his thought disorganization were greatly diminished. Discussions regarding his delusions about the government and religion in sessions significantly decreased, as did his reports of auditory and visual hallucinations. He was better able to track his own mental activity and self-redirect when he noticed tangential thoughts during sessions.
Dylan was able to maintain sobriety from drugs and alcohol during most of the course of individual therapy. Although Dylan began to occasionally use substances again in the middle stages of treatment, the quantity and frequency of his use were minimal and did not result in significant distress or impairment in functioning. During the final stages of therapy with his provider, Dylan also demonstrated an increased sense of agency in his decisions about his substance use and began to identify and use strategies for managing his use.
Dylan’s increased capacity for self-reflection and awareness of his thought disorganization and his lack of significant exacerbations of his symptoms or hospitalizations are promising factors for his future. Similarly, his significant overall reduction in substance use, greater capacity to reflect on the internal and external precipitants to his use, and increased sense of himself as an active agent in life also bode well for his future. Although gains in all metacognitive domains are possible with continued metacognitive therapy, Dylan has made significant progress in his abilities to understand and identify his own mental activity and has demonstrated increased understanding of the minds of others. He, therefore, appears in a good position for continued recovery and increased interpersonal functioning.
Limitations
This case illustration has a few limitations. This article has described an in-depth study of one person with schizophrenia, who presented with primarily disorganized symptoms. Therefore, these results may not be generalizable to patients with differing demographic characteristics or symptom presentations or those in different phases of their illness. Additionally, this case illustration reflects approximately three years of individual outpatient therapy with Dylan. Therefore, the extent to which these results may be generalizable to those engaged in shorter term treatment or other treatment settings is unclear.
Last, this case study provides an in-depth analysis of only one type of integrative metacognitive therapy. Other metacognitive therapies, such as skills-based metacognitive training (19), also address metacognitive deficits among those with psychosis. Future researchers may seek to address some of the limitations of the present case illustration, including examination of the effect of long-term integrative metacognitive therapy among clients with differing demographic characteristics and symptom presentations, to assess whether these individuals achieve similar treatment outcomes. More research is also needed that formally assesses metacognitive capacity throughout the course of treatment in both case study and control trial formats.
Summary and Implications for Clinical Practice
In the case presented, the therapist applied the eight elements of MERIT in synergy in the treatment of a middle-aged man with chronic schizophrenia and substance use disorder to attain greater levels of self-reflectivity, understanding of others’ minds, decentration, and mastery. Overall, Dylan’s gains in metacognitive capacity closely mirror results from other case studies (15, 20, 21) using integrative and metacognitively focused psychotherapy. Initial improvements in Dylan’s ability to reflect on his thoughts and feelings gave way to richer narratives, which then led to Dylan’s increased understanding of the problems he faced in his interactions with others. It is also of note that Dylan’s ability to detect, understand, and later intuit the thinking and mental states of others developed only after initial gains in self-reflectivity were achieved. These findings have implications for both conceptualization and intervention, because understanding the course of metacognitive growth may affect the intervention targets used by therapists.
As therapy progressed and Dylan’s narratives became richer and more linear, painful memories emerged of his past experiences with neglect, betrayal, and interpersonal loss. It became clear to the therapist that Dylan’s fragmentation provided him an element of protection from these painful memories. The relationship between his pain and his fragmentation was especially evident during therapy, given that Dylan’s disorganization frequently intensified after he provided narratives about past painful events. Similarly, in the middle stages of treatment he often became increasingly disorganized during the latter half of therapy sessions, which was reflective of the emotional and cognitive fatigue associated with reflecting on his life. These observations are consistent with previous case studies that have noted the relationship of increased insight and reflectivity with feelings of pain and loss (22, 23).
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Published online: 7 November 2018
Published in print: December 01, 2018
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The authors report no financial relationships with commercial interests.
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