Application of Integrative Metacognitive Psychotherapy for Serious Mental Illness
Publication: American Journal of Psychotherapy
Abstract
Recovery for many people with serious mental illness is more than symptom remission or attainment of certain concrete milestones. It can also involve recapturing a previously lost coherent and cohesive sense of self. The authors review several case studies of integrative metacognitive psychotherapy offered to adults with broadly differing clinical presentations. In all the cases, patients demonstrated significant subjective gains and objective improvements—for example, in negative symptoms, in substance use, and in overcoming a history of childhood sexual abuse. By applying this method to various problems—issues consistent with the realities faced in actual clinics—the authors explore how integrative metacognitive psychotherapy is able to address more subjective aspects of recovery by stimulating gains in the experience of agency that lead to the development of more cohesive self-experience, regardless of objective markers of recovery.
Decades of longitudinal research and first-person accounts have challenged long-standing pessimistic views of the course of serious mental illnesses, such as schizophrenia, demonstrating that recovery is a common and likely outcome (1). This work has also offered a growing portrait of the complexity of recovery from serious mental illness, emphasizing, among other things, that the meaning of recovery differs from person to person and is rarely as simple as symptom remission or the absence of adverse events, such as hospitalizations (2). Recovery can involve readily observable objective outcomes, such as becoming relatively symptom free or attaining psychosocial milestones. However, recovery most often also involves changes in some of the most subjective aspects of human experience, aspects that are not reducible to symptom management or skill attainment (3). For instance, a central task in recovery can involve recapturing a sense of agency—or the ability to affect one’s own life and destiny. Recovery can also entail regaining the ability to make sense of one’s experiences and ultimately develop or reconstruct a personal narrative that might inform more consensually valid engagements with others (3).
This work has spurred interest in the necessity of developing recovery-oriented treatments that move beyond a focus on skills or symptoms, are sufficiently flexible to respond to unique subjective experiences of patients, empower patients to take charge of their own recovery, and neither directly nor indirectly reinforce stigmatizing views of mental illness. An emerging recovery-oriented treatment that meets these criteria is integrative metacognitive psychotherapy (4). Metacognition is a term used originally in the context of education and later in cognitive science to signify a thought that concerns another thought (5). Metacognition has subsequently come to refer to the broad spectrum of activities by which persons develop integrated representations of self and others and use this information to respond to life’s challenges (6, 7). Metacognitive deficits have been broadly observed in early and later phases of serious mental illness and are believed to be the result of combinations of factors, including neurocognitive compromise, social isolation, stigma, trauma, and attachment style (8–11). Metacognitive deficits are closely tied to outcome and have been found to predict concurrent and prospective functional impairments (12–15).
Integrative metacognitive psychotherapy identifies metacognitive deficits as a treatment target (16). In general, this treatment seeks to stimulate growth in metacognitive capacity so that patients can become better able to integrate information, form complex ideas about themselves and others, and subsequently use that information to respond to psychosocial challenges. Applied to persons with serious mental illness, this treatment seeks to promote patients’ capacity to make sense of their own experiences, including the psychological and social challenges related to having a psychiatric disorder, so patients may be better able to direct their own recovery. In contrast to skills training approaches, which seek to help a patient learn how to do a certain activity, or more traditional cognitive therapies, which encourage persons to correct inaccurate or maladaptive beliefs, integrative metacognitive psychotherapy aims to assist persons in becoming better able to fit together fragments of experiences in a manner that enables full and meaningful participation in life.
This special issue features detailed case reports of the implementation of two forms of integrative metacognitive psychotherapy as adapted to psychosis—six of metacognitive reflection and insight therapy (MERIT; 17) and one of metacognitive interpersonal therapy (MIT; 18). Both MERIT and MIT are integrative in the sense that they bring together different techniques and processes within a treatment framework that is informed by an overarching theoretical model of metacognition as a precondition for making sense of and responding to serious mental illness. Each is also applicable to persons in very different states because both MERIT and MIT expect that interventions can and should be tailored to match patients’ current metacognitive capacity. To date, the support for MERIT has included a qualitative investigation, which suggested that MERIT leads to development of a sense of agency (19); an open trial, which suggested acceptability and clinical benefit (20); and a small randomized clinical trial reporting that MERIT led to gains in insight in first-episode psychosis (21). Support for MIT has come from case studies (18).
The case studies in this issue, consistent with a long-standing tradition calling for the exchange of nomothetic and ideographic findings (22), expand this work on the effects and processes of integrative metacognitive therapy by offering an opportunity for broader kinds of discovery not possible in larger controlled studies assessing uniform treatment targets. Although larger controlled studies may show that a certain treatment leads, in the aggregate, to a reduction in the same outcome (for example, reduced positive symptoms or hospitalization rates), this is often difficult to apply to actual clinical settings because persons with serious mental illness rarely report facing the same set of dilemmas in their lives. Consistent with the case studies in this issue, persons with serious mental illness experience an amalgam of complicated social, psychological, and biologically based challenges. A given patient may, for example, have limited social skills, a trauma history, positive symptoms, negative symptoms, dysregulated affect, comfort with the sick role, crushing social isolation, self-stigma, or disordered thoughts. Patients may experience some combination of any of these or other problems, and still other patients may have very different experiences of serious mental illness depending on whether they are experiencing the first episode of the disorder or have had many prolonged episodes over a number of years. Thus, the case studies of this issue, in contrast to larger effectiveness studies, allow us to look at the application of similar methods applied to very different problems of specific individuals, a paradigm that is probably close to realities faced by clinicians in practice settings.
In this introduction to the special issue, we address how the case reports of eight individuals with serious mental illness and their respective experiences in metacognitive therapy can illuminate how these forms of therapy provoke changes in sense of self, culminating in personally meaningful forms of recovery. First, we explore how, regardless of the status of objective markers of recovery, stimulating metacognitive capacity led to gains in the awareness of agency in these cases. We then explore how the emergence of agency served as the foundation for the development of a more coherent sense of self and then other tangible objective gains. Finally, we will touch on limitations and the need for future research.
A Path From Enhanced Metacognitive Capacity to Recovery
As noted above, clinicians encounter diverse patients facing varied problems related to their individual experiences of serious mental illness. Mirroring these clinical realities, among the cases presented in this issue are patients who have different issues: negative symptoms in early (23) and later stages of illness (24), chronic emotional dysregulation and suicidality (25), disordered thoughts and active substance abuse (26), persecutory delusions (27), emergence from an identity defined by illness (28), and prolonged effects of childhood sexual abuse (29). Also mirroring clinical practices, the therapists whose work is presented in this issue represent different disciplines (psychiatry, clinical psychology, and advanced practice nursing), have varying amounts of experience, and demonstrate practice tendencies tied to different psychotherapeutic traditions (cognitive-behavioral, humanistic, psychodynamic, existential, psychiatric rehabilitation, and so forth).
Consequently, each case involved therapists with differing styles and consideration of different kinds of content. Nevertheless, across cases, regardless of the specific presenting problems, the therapy focused on patients’ challenges, both psychiatric and general. The therapists in these reports did not begin with an intention to ameliorate or eliminate those problems. The presenting problems were not even necessarily in the foreground. Instead, in each case, therapy involved efforts to promote the metacognitive capacities needed to form more integrated ideas about oneself and others and then to use that knowledge to address psychosocial challenges, including prominent presenting problems as well as more nuanced difficulties that emerged during treatment. As metacognitive capacity began to emerge in each case, a range of other positive outcomes became observable. How did enhanced metacognition lead to recovery? Considering these cases as a whole, in what way did changes in metacognitive capacity lead to substantial changes in both subjective and objective outcomes?
The Initial Step: Emergence of Agency
In terms of the processes that culminated in different outcomes, we see metacognitive capacity as promoting a kind of initial change—namely, gains in a sense of agency. Patients in these case studies began therapy with little sense of personal agency, that is, as having little sense that they could understand or at least affect either external or internal experience. For example, one patient seemed unable to even discern the kinds of internal experience from which the basis for volition might take root (24). Another patient was overwhelmed and frozen in the face of persecutory delusions (27), and another was disabled by a history of profound childhood sexual abuse and lived in a state dominated by disorganized and bizarre persecutory claims (29). Another patient had seemingly no ability to do more than engage in grossly self-destructive behavior (25).
In the face of perceived lack of agency, each iteration of integrative metacognitive therapy presented in this issue addressed patients with the assumption that despite the pain and confusion, they were fully capable of recapturing a sense of their own agency and of using that to direct their own recovery. As therapists reflected with patients about the intentions, wishes, and hopes, no matter how unclear or fragmented, that the patients were experiencing in the moment, patients began to perceive themselves as striving toward something. As patients’ utterances and behaviors were continuously treated as meaningful and potentially understandable, this sense of agency deepened. Patients not only formed ideas about themselves and others but also began to recognize their behavior as purposive and experienced themselves as able to affect matters. Also evident is that in all the cases, ongoing reflection upon the relationship between the patient and therapist further grounded the developing sense of agency in the moment. Patients were agents operating in a definable interpersonal context.
Accordingly, a sense of agency was observed to grow out of a sustained joint focus on patients’ experience of mental phenomena, such as emotions, desires, wishes, and beliefs, as well as in the intersubjective processes of the therapy dyad. Regardless of whether the patient was in a more advanced state of recovery (28), in a state of prolonged disorder (26), or still reeling from a first episode of psychosis (23), there was shared reflection upon what was in the patient’s mind in the moment, as well as exploration of memories from across the patient’s life, which promoted a sense that the patient was an agent in the world. Knowledge of the patient’s subjective experiences further evolved across sessions as more sides of the person emerged and were either integrated into a larger picture of the person or were at least made available for potential integration in the future, serving as the basis for a deepening sense of agency.
Importantly, neither patients’ wishes and desires nor the larger interpersonal processes in the session were necessarily obvious, stable, or consistent. Most patients described in the case studies began with opaque, superficial, or externally attributed motives and expectations for therapy, and the qualities of the therapeutic relationship seemed to change rapidly and unexpectedly. Similarly, the emergence of agency was not simple or linear in any of these case reports. There was much that had to be thought about slowly over time, and each therapist had to confront his or her own feelings of confusion, anxiety, and vulnerability. Patients’ increased sense of agency and meaning was not something, therefore, supplied to them by therapists’ adoption of an expert role. Therapists did not offer patients a prepackaged narrative or explanation of the patients’ problems. Similarly, this awareness was not a matter of patients’ noticing something in their mind and having the therapist passively offer reassurance or affirm the accuracy of that perception or conclusion. Instead, through mutual reflection upon what was occurring in the moment as well as in past narrative episodes, the dyad explored and constructed a number of potentially contradictory, complementary, and unrelated ideas that illuminated and allowed for meaning to be made of the multiplicity of the patient’s experience. In this sense, a kind of feedback loop emerged in which agency and reflection reinforced one another.
Returning to the individual cases, with an enhanced sense of agency, both patients with negative symptoms began to experience and recognize their own desires and wishes in the moment and view themselves as able to experience and respond to life in general (23, 24). The patient with active substance use, rather than continuing to passively drift from day to day continuously using, began to be able to make sense of why he had abused drugs and alcohol; developing a rationale for his motives and an understanding of the consequences of his behaviors allowed for the potential to not use substances in the future (26). Persecutory delusions were no longer an unquestionable reality imposed on the patient but something that could be reflected upon (27). In the case described by Hillis and colleagues (29), the patient made sense of profoundly confusing statements and mental states as a meaningful consequence of devastating boundary violations experienced early in life.
The Second Step: Emergence of a More Cohesive Sense of Self
The second observable stage in the path from the emergence of metacognition to outcome is that the experience of agency interacting with metacognitive capacity spurred on the emergence of a more cohesive and coherent sense of self. Naturally, each patient described in this issue, as a function of individual personal, interpersonal, and sociocultural history, had a unique experience of the reemergence of awareness of agency. To be well and take charge of his or her life, therefore, meant different things to each individual. The experience of a lack of agency had innumerable negative qualities, including associated feelings of helplessness and demoralization. In each case, as a greater sense of agency emerged, patients appeared to more easily discern and reflect upon events in the world, and their feelings of helplessness and demoralization receded. However, this was not an easily welcomed and purely positive experience, because, even for the first-episode patients, the sense of a lack of agency had become routine, a predictable aspect of experience. According to observations by Buck and colleagues (30) as well as numerous first-person reports (e.g., 31), the emergence of agency was a departure from what was familiar and comfortable for these individuals. As the individuals began to move away from this familiar state, the solutions and responses to the challenges presented by this world became more complex. With a sense of agency, there were increasingly fewer “black or white” distinctions available.
Perhaps even more apparent in these case studies, a recaptured sense of agency was accompanied by pain. In the report by Buck and colleagues (25), enormous pain emerged as the patient formed a more complex account of his life, including consideration of how much he had destroyed and how many persons he had injured emotionally. As the patient in the case described by James and colleagues (26) began to manage his life more actively, profound needs for closeness and a deep sense of alienation emerged. For the patient described by George and Buck (24), emptiness gave way to a deep sense of hurt and a lack of basic security. In the case presented by Hillis and colleagues (29), as symptoms remitted, and agency emerged, the patient encountered the kind of profound suffering that often accompanies histories of childhood sexual abuse. In that case, painful ambivalence remained poignantly at the forefront throughout treatment, as the patient acknowledged near the end of therapy that despite the obvious progress he had made, part of him continued to wish for the therapist to reject him.
Following the emergence of agency, a somewhat different process began in each case that seemed closely tied to the development of a more coherent and cohesive sense of self. We are referring here to the points at which therapists assisted patients to think about and become “used to” or “comfortable with” the experience of agency. This involved the dyad’s not only noticing that the patient was having an experience of agency but also reflecting on the complexity of that experience of agency. This appears clearly in the case described by Buck and colleagues (25), as the patient began to take charge of his life and was surprised that he was becoming less and less self-destructive. There was a similar process in the case described by George and Buck (24), in which the patient seemed to be directly noticing that the experience of agency and the ability to reflect about himself did not cohesively fit with his larger sense of self.
In this second phase, therapy appeared to involve direct reflection on patients’ experiences of agency. Ultimately, the patients’ reactions to both the newness of their agency and the uniqueness of their wishes led to one of the most subjective of recovery outcomes—the development of a more cohesive and coherent sense of self. Patients appeared increasingly able to understand complex elements of experience, accompanied by the development of an improved sense of self. They could accept loneliness (28), allow for contradictory reactions to others (29), and make sense of long patterns of self-destructive decisions (26). Just as a feedback loop was observed earlier between agency and metacognition, in this phase we see a larger feedback loop with a more coherent sense of identity provoked by and then feeding back into and reinforcing agency and metacognition.
The Third Step: Action and Objective Outcomes
As patients became more comfortable with being an agent in their daily lives and as a more complex and coherent identity set in, we noticed that some of the most objective changes occurred. In other words, after agency emerged and patients adjusted to being an agent in the world and developed a richer sense of themselves, more easily observable changes were made, and each patient began to view recovery as something that only he or she could direct. For instance, the patient in the case presented by Leonhardt and colleagues (23) demonstrated remarkable progress across a range of objective markers, including reengagement in creative arts, finding competitive employment, and shoring up relationships. Similarly, the patient in the case described by Hillis and colleagues (29) formed deeper relationships with family and community members and was able to begin living in a home of his own. In another case, the patient reduced and then ceased to rely on alcohol as a means of managing distress (26). Still others demonstrated subtle but meaningful objective changes, such as the patient in the case presented by George and Buck (24), who began to walk at a more typical pace and recapture a sense of humor. Nearly all the patients showed improvements in symptoms, and although some continued to face persistent moderate levels of symptoms, they were better able to recognize their own agency and develop a more meaningful account of their experiences, including their symptoms.
As we noted in the other phases, we would again suggest that we are observing a feedback loop in which the interaction of the emerging metacognitive capacity, agency, and cohesive sense of self provokes action that itself feeds back to and supports all these activities.
Integrative Metacognitive Psychotherapy: Summary and Considerations
In sum, these cases offer support for the possibility of offering a metacognitive psychotherapy framework to persons with serious mental illness. These cases illustrate how this therapy can be accepted by persons with serious mental illness, delivered in naturalistic settings, and result in meaningful recovery-oriented gains. These cases also demonstrate that this therapy can be delivered to patients in various stages of recovery and is not something patients can receive only when sufficiently “stable.” Moreover, the variety of presentations and experiences illustrated in these reports offers insight into how these approaches might be tailored to fit the broad needs of diverse people while maintaining a focus on integrative processes and the whole person and without breaking the therapeutic process into a number of loosely related efforts focused on specific problems.
Contrary to some contentions that depth-oriented therapies may be harmful (32), none of these case reports indicated that any form of regressive process was provoked by therapy. Likewise, some phenomenological accounts have expressed concerns about possibilities that interventions encouraging certain forms of reflection may be harmful to persons with psychosis by inspiring rumination and hyper-self-consciousness (33). In the eight courses of therapy described here, and consistent with a previous line of detailed case reports (34–40), there is no evidence indicating that metacognitive therapy leads to dysfunctional or morbid self-reflection.
Concerning the issue of insight and recovery, a long-standing tradition suggests that patients with schizophrenia lack the abilities to make sense of their own symptoms and need psychoeducation to move forward (41). However, a growing body of work suggests that health begins not with insight but with rejection of a passive role (2). These cases offer evidence that psychotherapy can lead to insight and that insight is not a precondition for the development of a sense of agency or self-coherence. Acceptance of a psychiatric label or acknowledgment of illness was irrelevant to the processes described here. In these case studies, we see how integrative metacognitive psychotherapy promoted patients’ abilities to recognize themselves as agents in the world, no matter how fragmented that awareness may have been. It was certainly the case that individualized narrative conceptualization of psychiatric challenges emerged, although that awareness (that is, insight) was never a matter of passively agreeing with a psychiatric label or with the interpretations of the healthy and more powerful treatment provider. Instead, in these cases, insight was developed regardless of whether the patients chose to agree with the diagnostic label and was separate from the degree of symptom remission. In each case, the therapist partnered with the patient in the spirit of making sense of his or her life—the distressing and confusing aspects as well as areas of intact health and striving—and reflected on this matter in a fashion that allowed the patient to form a more integrated and meaningful account of him- or herself, others, and the patient’s surroundings.
Importantly, despite the value evident in the case material, this approach is not without its limitations. Controlled trials, as well as more qualitative and case-based research, are needed to validate these approaches. Although the courses of treatment described in these cases varied considerably in length, MERIT and MIT have been developed and offered, in general, as forms of long-term psychotherapy, and the cases here appear to demonstrate the value available to some patients who are able to participate in this kind of psychotherapy. To date, little guidance is available about expected length of treatment or about factors that might indicate when a more abbreviated course of treatment would be helpful when the clinical setting precludes long-term work or if the patient does not have the ability or willingness to engage in long-term work. Furthermore, although we have proposed one model to explain change, alternative explanations exist, and further investigation is needed to better understand how persons can meaningfully recover, despite experiencing profound suffering and disorder.
Finally, it remains unclear how these metacognitive approaches fit with or contradict current trends in the literature. Specifically, certain aspects of integrative metacognitive therapy appear to line up well with broad trends, in the sense that they have been designed to be consistent with global trends emphasizing recovery-oriented care systems and treatments that encourage choice and self-direction. However, a trend in the field continues toward increasingly specific interventions designed to remediate discrete problems and promote rehabilitation of social and functional skills. The integrative metacognitive approaches featured in this issue diverge from this trend, actively discouraging therapists from adopting the expert or educator role that professionals often take in certain approaches that promote skill development and psychoeducation. Clinics routinely must deal with competing pressures to offer services that are recovery oriented and that support self-determination and client choice while also tackling such immediate concerns as lack of adherence to treatments and risk management. We are optimistic that integrative metacognitive psychotherapy offers a synthesis of existing approaches. We believe that it may afford professionals a treatment framework, informed by empirical research, which promotes the reflective capacities needed to make sense of experiences and progress from states of fragmentation toward increased integration and recovery.
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Received: 10 January 2017
Revision received: 17 January 2017
Accepted: 4 September 2018
Published online: 10 October 2018
Published in print: December 01, 2018
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The authors report no financial relationships with commercial interests.
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