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

The client for this case will be referred to as Grohl. All identifying information has been altered to protect his confidentiality. Grohl is a single male in his early to mid-20s who was diagnosed as having schizophrenia two years prior to his engagement in therapy. He grew up as the eldest of three children in a middle-class family and reported no developmental concerns or delays. Grohl described himself as having many friends during his childhood and reported he was involved in extracurricular activities and performed well in school. Prior to his diagnosis of schizophrenia, he had no other mental health diagnoses or mental health treatment. He was a talented artist and was active in his high school’s art community. He and his parents noted a change after high school in which Grohl became less social and struggled academically in his college classes. Immediately after high school, Grohl relocated from living with his family of origin to living with his grandfather in a different city in the same state. He had limited contact with his family of origin during that time and began to experience a change in his level of psychosocial functioning: socially withdrawing, failing to keep jobs, and eventually dropping out of school. Grohl’s grandfather struggled with substance abuse during this time and was actively using substances while Grohl lived with him. Grohl and his parents reported that there were often verbal and physical fights as a result of Grohl’s grandfather’s substance use and overall this was a tumultuous time for Grohl. Grohl’s own substance use included occasional marijuana and alcohol in high school, and he reported drinking alcohol several times per week while living with his grandfather. He had legal charges related to an arrest for underage drinking.

During the onset of Grohl’s illness, he began to believe a range of persecutory delusions that often centered on his physical health, stating that others were poisoning him and noting strange physical sensations that he believed were a result of the poison he was administered. His grandfather took him to a behavioral health center where Grohl was diagnosed as having schizophrenia and an oral second-generation antipsychotic was prescribed, which he took intermittently. Grohl lived with his grandfather and occasionally sought medical assistance for physical sensations for one-and-a-half years before he visited emergency rooms in several states, attempting to convince hospital staff that he was being poisoned and requesting medical attention. Grohl would leave the emergency room before care could be administered. He was eventually detained by the police due to erratic behavior and was transferred to an inpatient hospital close to his parents’ residence. It was following this hospitalization that Grohl was linked to the early psychosis clinic. While on the inpatient unit, Grohl was involuntarily committed due to his refusal to take medications and his attempts to leave the unit against medical advice. He began receiving an injection of paliperidone palmitate. Grohl eventually moved to a supported living environment and attended an outpatient clinic, receiving case management and medication services for six months before agreeing to psychotherapy. He remained on a stable dose of his medications during the duration of the therapy presented below, and he received services from a multidisciplinary team, including case management and supported employment services. In addition, because of Grohl’s somatic complaints, he received care at several primary and specialty care clinics to evaluate his health. He received a diagnosis of gastroesophageal reflux disease and was treated for this condition. He received no other medical diagnoses.

When Grohl began therapy, he was primarily experiencing negative symptoms. He experienced thought blocking, prolonged response latency, anhedonia, and flat affect. He described that his mind was “empty” and noted that he spent much of his day lying in his bed. Grohl was unemployed at the time and saw his family once per week when his parents picked him up for a family Sunday dinner. He had no other social contact. He endorsed avolition, noting that despite being bored much of the time he was not motivated to engage in any behaviors that he used to find enjoyable, such as creating art, spending time in Internet forums, or spending time with his friends. Grohl was quiet, rarely made eye contact, and often came to his psychotherapy session appearing disheveled.

Grohl’s deficits in metacognition were assessed with the Metacognition Assessment Scale-Abbreviated (MAS-A; 15), which is an adaptation of the original MAS (16) and includes four domains of metacognition: self-reflectivity, awareness of others, decentration, and mastery. Each part of the scale is hierarchical, with higher scores representing increased capacity to perform the complex mental tasks of each domain. Self-reflectivity refers to the ability to acknowledge and identify internal states and to ultimately form flexible understandings of oneself and one’s unique life events over time. Grohl initially had low self-reflectivity. Although he was able to distinguish a range of cognitive operations, he was unable to name a nuanced range of emotions or recognize that his thoughts were fallible, giving him a score of 3 out of 9 on the self-reflectivity scale. For example, Grohl remained convinced that he was being poisoned by an unnamed entity and remained adamant that he had holes in his head that were causing discomfort in his body. Awareness of others refers to the ability to consider other people’s internal states and to make guesses about their intentions. Grohl also scored low in this capacity. He recognized that others had their own internal states but was unable to name a range of emotions significant others in his life might experience and struggled to guess their intentions. He was evaluated at a 3 out of a possible score of 7 on this subscale of the MAS-A. Decentration refers to the ability to recognize that one is not the center of all activities and that other people have differing, valid opinions separate from one’s own. Grohl tended to view events as being connected to him, often believing that others wished him harm, and failed to consider that others in his life had lives outside of his. He scored 0 out of 3 on this scale. Finally, mastery refers to the ability to use knowledge about oneself to respond in increasingly complex ways to psychological problems. Grohl initially came to therapy without a clear psychological problem, often stating that something had gone wrong in his life but attributing that distress to the malicious, unnamed individuals who he believed were causing his physical sensations. Thus, his score on mastery was a 1.5 out of 9.0 because he did not meet the criteria of articulating a plausible psychological problem.

The therapy described below refers to an 18-month period of weekly individual psychotherapy utilizing MERIT. MERIT is an integrative psychotherapy with eight core elements incorporated into each session. These elements can be used along with a range of therapeutic approaches and offer therapists a method of building upon existing skills and conceptualizations and employing a flexible framework that centers on increasing the client’s metacognitive capacity (17). Each of these elements is briefly defined below, along with a description of how that element was addressed in Grohl’s psychotherapy.

Significantly, Grohl appears to have made gains in his personal recovery. At the beginning of therapy, he was unemployed and isolated, and much of his focus (including interactions with his family) was on his physical experiences. Within two years of starting therapy, Grohl’s life looked considerably different. He has been employed for 18 months at one job and recently added a second job. He has reconnected with his family members and sees them several times every week. He has reestablished an old friendship and begun two new ones. He engages with his community by creating murals for the church he attends and taking other offers to generate art. Additionally, he lives independently in an apartment, has bought a car, has gotten a pet, and has other accomplishments that seem to illustrate a dynamic life. As Anthony (19) points out, the meaning of recovery for each individual is deeply personal, and thus Grohl’s own subjective sense of recovery is the best marker for whether or not he is in recovery from his severe mental illness. Grohl describes in therapy sessions that he has an improved quality of life, expressing that while he still feels anxious and unsure about taking chances on his future, he feels more fulfilled with his current life than he did two years ago. He articulates an improved sense of self-esteem and appears to experience himself as an agent, even making decisions about his mental health care and how and when he will engage in it. He seems to rely less on his parents to make decisions for him, although he considers their advice. Grohl is actively pursuing higher education opportunities and has been reflecting on what type of career he would like. He is planning to start college within the next year.

Thus, while this case has results similar to other case studies using MERIT for patients with FEP, such as an increase in insight and decrease in symptoms (14), Grohl’s case also illustrates the movement from being dominated by a mental health condition to living a more fulfilling and enriched life in recovery. While this case occurred within clinical practice and thus other contributing and confounding factors cannot be ruled out, it seems likely that the use of MERIT promoted Grohl’s recovery. We posit that MERIT promotes recovery for two reasons: first, each of its elements supports the core values of recovery, and second, metacognitive capacity may be necessary to achieve many of the subjective elements of recovery.

By starting with the first of these two assertions, that the eight elements of MERIT support the tenets of recovery, we see that elements 1, 4, 5, 6, 7, and 8 all position the client as an agent with an agenda, a mind for dialogue, and an active participant in care, thus encouraging self-direction. Element 1, or the preeminent role of the client’s agenda, places importance on understanding what the client wants in a given moment, creating a therapeutic environment with multiple pathways to recovery, tailored to what is important to the individual and allowing for self-direction. MERIT promotes an open stance, in which the therapist does not operate as an expert but rather as a consultant, serving as a guide to explore the content of one’s own mind. The MERIT therapist does not merely mirror the client, but in addition to providing reflections of the client’s mind, actively offers his or her own thoughts to discuss and react to within the therapy encounter (elements 2 and 5). MERIT also supports recovery through the therapist’s interest in the client’s story and life before and after illness, helping the client recapture a sense of self rather than just focusing on symptom relief or eradication of unhealthy thoughts and behaviors (element 3). Thus, all eight elements of MERIT support the core values of recovery.

Turning to the second assertion, MERIT may assist persons in the types of sense-making that are necessary to achieve subjective recovery. For example, having a storied sense of one’s life as having good moments as well as challenges aligns with the recovery tenets of seeing oneself as more than a mental health patient, feeling empowered to make decisions about one’s life, and ultimately recapturing a sense of self. By contrast, having significant metacognitive deficits may make achieving subjective elements of recovery difficult if one is struggling to identify one’s own hopes and dreams and to understand and respond to psychological challenges. Thus, it may be that by promoting metacognitive capacity through the eight elements of MERIT, therapists are able to assist clients in forming flexible, coherent understandings of themselves, others, and their unique challenges in life and begin to respond to them.

Significantly, Grohl made gains on each of the four metacognition subscales. Grohl began to describe and recognize a range of nuanced emotions; began to view his thoughts as fallible and thus changeable; believed that his expectations were not always reality; and began to integrate his thoughts, feelings, and behaviors when thinking about specific narrative episodes of his life. Thus, Grohl moved from a 3 to a 6.5 on self-reflectivity. He also began to see other people as having rich internal experiences and began to make guesses about their intentions using unique information about them, thus moving from a 3 to a 5 on awareness of others. Grohl initially scored a 0 on decentration, as he thought all others were somehow tied to a conspiracy against him. He developed a different view, however, and was able to see others as having their own lives separate from him, and he even began to consider that other people have valid but differing opinions from him, placing him at 1.5 on the scale. Finally, Grohl developed a plausible psychological problem and began to use behavioral strategies, such as engaging in artistic endeavors, to manage his distress, moving him from a 1.5 to a 5 on the mastery scale.

Although case studies provide in-depth examinations of an individual’s experience, they have limitations. The findings from this case study may not be generalizable to other individuals. More work is needed with individuals of differing demographic characteristics and phases of illness to assess the generalizability of these findings. Additionally, other factors external to Grohl’s psychotherapy may have had an impact on his ability to recover, including other services he received, such as medication management and supported employment services. Despite these limitations and given the larger body of literature and the findings of this case, MERIT appears to be a promising intervention that may help promote recovery for patients with FEP.