Paul Lysaker

Richard L. Roudebush VA Medical Center · Department of Psychiatry

Background Disrupted metacognition is implicated in development and maintenance of negative symptoms, but more fine‐grained analyses would inform precise treatment targeting for individual negative symptoms. Aims This systematic review identifies and examines datasets that test whether specific metacognitive capacities distinctly influence negativ...

Homework assignments, or specific tasks patients are asked to engage in or complete between sessions, are a controversial topic among psychoanalysts. While many argue these interventions contradict psychoanalytic principles, others believe they can help address problems and promote coping skills. We propose that homework can be a legitimate aspect...

Metacognitive deficits have been proposed as a transdiagnostic construct that may underpin the phenomenology of multiple mental health disorders. In this chapter, we explore how this model has been applied to schizophrenia in particular and how this application could be adapted to explain the phenomenology of schizotypy, both as a personality organ...

This timely volume explores the range of personality traits and psychosocial deficits which are associated with the broadly defined construct of schizotypy. Describing schizotypy as a phenomenon that can be located on a continuum ranging from sub-clinical states to severe disorders, the editors have brought together experts in this field to discuss...

Introduction Recovery from psychosis is an expected and desired outcome in psychiatric rehabilitation that may involve subjective outcomes related to personal recovery. While a considerable amount of qualitative research has examined patients’ experience of recovery oriented approaches, there are less studies examining clinicians’ perspectives. Exa...

Purpose: Negative symptoms are a persistent, yet under-explored problem in psychosis. Disturbances in metacognition are a potential causal factor in negative symptom development and maintenance. This meta-analysis uses individual participant data (IPD) from existing research to assess the relationship between negative symptoms and metacognition tr...

Background: Research has suggested that people diagnosed with schizophrenia experience challenges in their abilities to reflect upon themselves, others and their actions in the world. One emerging approach to addressing these forms of subjective disturbance is Metacognitive Reflection and Insight Therapy (MERIT). Aims: In this study, a randomize...

BACKGROUND: Self-esteem and depressive symptoms contribute to a lower quality of life in people suffering from eating disorders. However, limited research has examined whether other factors may affect how these variables influence one another over time. Metacognition is a previously unexplored determinant that may impact the relationships between s...

Metacognition has been defined several ways across different fields. In schizophrenia, two primary approaches to assessing metacognition focus on measuring metacognitive beliefs and metacognitive capacity. The degree of association between these two approaches is unclear. In this pilot study, schizophrenia (n = 39) and control (n = 46) groups were...

Dis-sociality (DS) reflects the impairment of social experience in people with schizophrenia; it encompasses both negative features (disorder of attunement, inability to grasp the meaning of social contexts, the vanishing of social shared knowledge) and positive features (a peculiar set of values, ruminations not oriented to reality), reflecting th...

Hope is known to be a crucial factor that can facilitate recovery from psychosis. In contrast, hopelessness has been associated with a variety of poor outcomes for people with psychosis, such as low self-esteem, depression, and suicide. While hope is central to recovery, the concept of hope can be challenging to identify and define. Furthermore, li...

Introduction: The experience of psychosis involves changes in an individual's sense of self and their understanding of others and the world around them. Studying life narratives and narrative identity offers one way to better understand these changes. Areas covered: Narratives of persons with psychosis display alterations in their themes, struct...

Homework assignments in psychoanalysis are contentious; some believe they contradict psychoanalytic principles, while others argue they enhance coping skills. We propose that homework can be a legitimate aspect of relational psychoanalysis when used in a way that is attuned to the patient’s experience and that homework may be an important component...

Alexithymia, or deficits in emotion recognition, and metacognitive capacity have been noted both in psychosis and eating disorders and potentially linked to psychopathology. This study sought to compare levels of impairments in these phenomena and their associations with psychopathology in groups with eating disorders and psychosis. Participants wi...

Background There is a growing interest in the early assessment and treatment of maladaptive forms of personality traits in adolescents, though little is known about effective interventions. This case series aims to present the adaption of a therapy specifically tailored on schizotypal traits to adolescents. The treatment – Evolutionary Systems Ther...

Background: Impaired cognitive insight and increased self-stigma have been consistently reported in individuals diagnosed with schizophrenia spectrum disorders, but little is known about its presence in individuals at ultra-high risk of developing a psychosis, although self-stigma is associated with transition.to psychosis. The current study exami...

Objective: Psychotherapy as a practice in the field of psychiatric rehabilitation is increasingly seen as a means to promote recovery from serious mental illness (SMI). While mostly informed by mental health theory and research, art might offer profound and enduring insights to inform psychotherapy with people with SMI. In this article, we argue t...

Recovery from psychosis involves deep and subjective personal changes such as regained sense of agency and purpose. Metacognitive Reflection and Insight Therapy (MERIT) is a form of person-centred psychotherapy that promotes recovery-oriented outcomes by enhancing metacognitive capacity, i.e. one’s ability to monitor and regulate cognition and beha...

Background Schizotypal personality disorder is characterized by a pervasive pattern of maladaptive behavior that has been associated with the liability for schizophrenia. Little is known about effective psychosocial interventions. This pilot non-inferiority randomized controlled trial aimed to compare a novel form of psychotherapy tailored for this...

Technological advances in artificial intelligence and natural language processing have increased efficiency of assessing speech content and speech organization in schizophrenia. Despite these developments, there has been little focus on the psychometrics of these approaches. Using two common assessments, the current study addressed this gap by: 1)...

Objective: While recovery from psychosis is possible, recovery is a multidimensional construct driven by various factors. One relevant factor to recovery from psychosis that has often been overlooked in the psychotherapy literature is the importance of facing loss and processing grief in relation to psychosis. Methods: A review of the existing em...

Background While many persons with serious mental illness (SMI) consider intimate relationships and becoming parent as central parts of their lives deeply affecting wellbeing and recovery, others anticipate facing multiple challenges in these life domains. This qualitative study sought to explore the perspectives of persons with SMI and mental heal...

Reduced metacognitive abilities—difficulty making sense of and understanding oneself and others—have been found to be key predictors of social functioning across a range of clinical and nonclinical groups. However, the exact processes through which metacognition impacts social functioning are unclear. This study examined whether subclinical negativ...

Background. Metacognitive Reflection and Insight Therapy (MERIT) is a manualized, evidence-based approach that supports occupational participation through its focus on the inter-related constructs of meaning making, positionality, and self-definition (Lysaker et al., 2020). MERIT's core tenets parallel the fundamentals of occupational therapy, maki...

Disorganized speech is a key component of formal thought disorder (FTD) in schizophrenia. Recent work has tied disorganized speech to deficits in metacognition, or one's ability to integrate experiences to form complex mental representations. The level of FTD at which differences in metacognitive capacity emerge remains unclear. Across two studies,...

Despite pessimism in the field, persons experiencing psychosis can benefit from psychotherapy and recover. However, there are multiple factors that can interfere with the formation of a positive therapeutic alliance and lead to the premature termination of therapy, which is associated with poorer long-term outcomes. In this article, common therapis...

For people with psychotic disorders, developing a personal narrative about one’s experiences with psychosis can help promote recovery. This pilot study examined participants’ reactions to and experiences of participatory video as an intervention to help facilitate recovery-oriented narrative development in early psychosis. Outpatients of an early p...

Background and Hypothesis Disturbances in self-experience are a central feature of schizophrenia and its study can enhance phenomenological understanding and inform mechanisms underlying clinical symptoms. Self-experience involves the sense of self-presence, of being the subject of one’s own experiences and agent of one’s own actions, and of being...

Deficits in metacognitive capacity (i.e., the ability to integrate knowledge of oneself and others into a cohesive whole) have been shown to lead to poor functional outcome in psychosis. However, there is a gap in the literature concerning the role of metacognition in typically developing populations, which makes it difficult to define what level o...

Background Research suggests that in-session emotional experiences in psychotherapy promote both session and treatment outcomes across different clinical samples and treatment approaches. However, little is known about how this notion applies to clients with schizophrenia, who experience particular deficits related to emotional experience. To explo...

For more than a century it was commonly asserted that people with psychosis experience a process of ongoing decline, resulting in prolonged and unremitting psychosocial dysfunction. As research has engaged people with psychosis and conducted long-term follow-ups, this pessimistic view has been challenged and recovery has been proposed as the expect...

Metacognitive reflection and insight therapy (MERIT) is an integrative individual psychotherapy which aims to improve metacognition and insight in people with serious mental illness. In response to limitations of MERIT and the growing clinical demand for new cost-effective group psychotherapies, we developed a group-based MERIT intervention (MERITg...

Recovery from serious mental illness (SMI) is recognized as involving the development of a coherent and compassionate understanding of oneself and one’s place in the world. For many reasons this may be an unusually daunting task in a maximum security prison, particularly in solitary confinement. For the incarcerated person who experiences psychosis...

Metacognitive reflection and insight therapy (MERIT) is an one-on-one intervention that targets insight with the aim to help people with serious mental illness develop more integrated ideas about themselves and others in order to respond to their psychological and social challenges more adaptively. There is a growing body of evidence on MERIT's eff...

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Background Impaired insight poses a challenge in the treatment of patients with schizophrenia because of its potential to jeopardize therapeutic engagement and medication adherence. This study explored how insight impairment, graded from none to extreme, is related to patient-reported mental health status, depression, and neurocognition in schizoph...

Introduction: Subjective cognitive deficits have been broadly reported in schizophrenia and described by Huber as basic symptoms. It remains unclear however to what extent they may be related to psychosocial stressors including trauma. Methods: We assessed basic symptoms using the Frankfurt Complaint Questionnaire (FCQ) in a sample of 40 patient...

Studying narrative identity has become a route to understanding alterations in subjective experience and compromises in quality of life or “the good life” in psychosis. In this paper we examine how research on deficits in metacognition in psychosis may help us understand one aspect of compromise in narrative identity, a lack of responsivity to expe...

Background: Research supports the possibility that a person's metacognitive ability may influence the impact of positive symptoms. This connection is important because understanding how metacognitive capacity relates to positive symptoms and distress can guide treatment and bolster recovery. Aims: To explore this, we assessed the moderating role...

Deficits in metacognitive capacity are common among people with serious mental illness (SMI), although there is a gap in knowledge regarding how these impairments predict later functioning, especially employment. This study aimed to prospectively examine the relationship between metacognitive capacity and 6-month competitive employment attainment i...

Despite its importance in the provision of mental health treatment, the availability of high-quality clinical supervision faces numerous threats in the public sector. Access to high-quality supervision may be especially important for therapists providing services to persons with psychosis. Here, we detail one supervisory approach that has been deve...

Unique deficits in synthetic metacognition have been found in schizophrenia when compared with other psychiatric conditions and community controls. Although persons with autism spectrum disorders (ASD) display similar deficits in social cognition relative to those with schizophrenia, to date no study has compared metacognitive function between thes...

Background Current research suggests that stressful life experiences and situations create a substantive effect in the development of the initial manifestations of psychotic disorders and may influence temporo-limbic epileptic-like activity manifesting as cognitive and affective seizure-like symptoms in non-epileptic conditions. Methods The curren...

Introduction: Poor insight, or unawareness of morbid changes in cognition, emotional states, or behavior, is commonly observed among people with schizophrenia. Poor insight represents a persistent barrier to wellness because it interferes with treatment and self-direction. Paradoxically, good insight may also be a barrier to health when awareness...

Background: We aimed to investigate whether personal recovery levels differ between those in early vs prolonged phases of psychosis and if there are different associations with objective outcomes of recovery (i.e., symptom severity and level of functioning). Method: Participants included 131 patients with early psychosis and 83 patients with pr...

Poor clinical insight is one of the most common features of schizophrenia spectrum disorders and plays a critical role in prognosis and treatment. Considering the biological and phenomenological overlap between schizophrenia and bipolar I disorder with psychotic features (BID) and increasing incidents of methamphetamine-induced psychotic disorder (...

Contrary to long-standing views, science does not bear out the assertion that psychosis is, by definition, a process of continuous decline ending in chronic dysfunction. Instead, people diagnosed with very significant forms of psychosis recover overtime in substantial and meaningful ways. To explore this issue, this chapter will offer a brief overv...

Substance use exacerbates psychosis, mania, depression, and poor functioning in people with first episodes of psychosis (FEP) and is associated with poor treatment outcomes, even when it does not reach the level of a formal disorder. Impaired insight and substance use are common issues that may interfere with treatment outcomes among people experie...

Objective Metacognitive oriented treatments are novel therapies designed to address metacognition deficits in schizophrenia, defined as the set of mental activities that allows reflection on oneself and others, and the integration of this knowledge into sophisticated mental representations that guide adaptive responses to life’s demands and to the...

Historical and contemporary perspectives have argued that alterations in self-experience in psychosis can be reversed with the help of psychotherapy. Less is known about the particular forces that spur such change, though it has been argued that intersubjectivity in the therapy dyad contributes to shared meaning making that enables movement toward...

Introduction: Social functioning is often impaired in the ultra-high-risk (UHR) phase of psychosis. There is some evidence that empathy is also impaired in this phase and that these impairments may underlie difficulties in social functioning. The main aim of this study was to investigate whether cognitive and affective empathy are lower in people i...

Many with psychosis experience substantial difficulties forming and maintaining social bonds leading to persistent social alienation and a lack of a sense of membership in a larger community. While it is clear that social impairments in psychosis cannot be fully explained by symptoms or other traditional features of psychosis, the antecedents of di...

A considerable body of phenomenological research has described different ways in which the relationship of the person to the world in psychosis is affected. This literature, however, has lacked an accepted unifying theoretical model and means of quantitatively measuring these disturbances. To address this, the current article seeks to integrate a n...

Growing awareness that many who are diagnosed with schizophrenia recover has spurred the development of new psychosocial approaches to treatment. These new approaches include forms of individual and group psychotherapy whose focus extends beyond reducing symptoms and improving skills to subjective outcomes related to sense of self. This paper intro...

Introduction Difficulties forming an integrated sense of oneself, others, and one's place in the community have been observed to pose a barrier to recovery from schizophrenia spectrum disorders (SSD). This has promoted the development of metacognitive approaches to psychotherapy that seek to assist persons in making sense of and managing their psyc...

Objective: When clients' lives are not reflected in therapy, they struggle to apply the skills learned in treatment to everyday situations. In this pilot study, we determined if using clients' real-world interactions in therapy could effectively target metacognitive capacity-yielding improved symptoms and social functioning-by tailoring treatment...

Introduction This issue of In Session in The Journal of Clinical Psychology offers in depth case studies of psychotherapy for persons with differing types of schizophrenia spectrum disorders across international settings. Method To understand the context and import of this work, this commentary explores commonalities of this work with past work in...

The resistance of negative symptoms to pharmacologic treatment has spurred interest in understanding the psychological factors that contribute to their formation and persistence. Accordingly, recent research has suggested that deficits in metacognition, or the ability to form integrated ideas about oneself, others and the world, are involved in the...

People diagnosed with schizophrenia have been broadly observed to experience deficits in clinical and cognitive insight; however, less is understood about how these deficits are related. One possibility is that these deficits co-occur among people when other deficits in cognition are present, such as in executive function, social cognition, and met...

Research using the integrated model of metacognition has suggested that the construct of metacognition could quantify the spectrum of activities that, if impaired, might cause many of the subjective disturbances found in psychosis. Research on social cognition and mentalizing in psychosis, however, has also pointed to underlying deficits in how per...

Metacognitive reflection and insight therapy (MERIT) is an integrative form of psychotherapy which seeks to help adults with serious mental illness make sense of the psychosocial challenges and possibilities they face and decide how to respond to them and direct their own recovery. In this article, we present an adaptation of MERIT to the context o...

In this volume, the collected chapters have described approaches to the treatment of psychosis that have shifted their focus from symptom reduction and skill acquisition to helping persons make their own sense of the challenges they face and how to manage them. While many different approaches have been presented, we suggest that these chapters offe...

Emerging evidence from studies on the subjective experience of recovery from psychosis indicates that mental health services need to move beyond seeking to reduce symptoms or promote skill acquisition. Wellness, as it is increasingly defined in terms of mental health, recognizes that services need to take into account the sense people make of the c...

Background Autobiographical memory is an important component of declarative memory, which refers to the ability to recall personal events that happened in the past. This requires that the person senses or experiences himself/herself in the past (i.e., conscious recollection). For people with schizophrenia, conscious recollection can be particularly...

Background Poor clinical insight has been commonly reported in those with First Episode Psychosis (FEP) and thought to be influenced by a range of factors, including neurocognition and symptoms. Clinical insight may be compromised as a result of alterations in higher-level reflective processes, such as metacognitive ability and cognitive insight....

Objective The Illness Identity model posits that self‐stigma reduces hope and self‐esteem among persons with severe mental illnesses, impacting a range of outcomes. The “insight paradox” anticipates that the negative effects of self‐stigma are amplified by insight. This study tested these predictions using both cluster and path analyses. Method A...

Objective Schizophrenia is increasingly understood as an interactive network of disturbances in different elements of self-awareness. In this study we have examined the relationship between disturbances in two forms of awareness: cognitive insight and clinical insight by exploring whether their relationship is mediated by a third form of larger awa...

Racial status has an important role in schizophrenia, with African American samples being rated lower than White participants on a range of constructs. In many studies, however, demographic factors are not accounted for. In the present study, African American (n = 106) and White participants (n = 81) were compared on symptom severity and emotion re...

Objectives: To promote functional recovery in persons diagnosed with a psychotic disorder, vocational interventions have emerged over the last few decades which range from sheltered employment to supported employment in the community. Design: Using data from a 6-month vocational rehabilitation programme, we examined whether assessments of the th...

Background: This post hoc analysis of clinical trial data evaluated long-term, self-reported mental and physical health-related quality of life (HRQoL) scores in schizophrenia patients receiving aripiprazole lauroxil (AL), an atypical long-acting injectable (LAI) antipsychotic approved for the treatment of schizophrenia in adults. Methods: The s...

While the clinical significance of therapeutic alliance with persons with psychosis is well established, the agreement between client and therapist assessments of therapeutic alliance and the longitudinal changes of both assessments has been rarely addressed. The current study examined client and therapist assessments of therapeutic alliance longit...

Shared decision making (SDM) is an interpersonal health communication model that is underutilized with people with serious mental illness. Although research has emphasized the role of patient capacity–, clinician-, and system-related barriers in SDM underutilization, the risk taking that affects SDM with people with mental illness is less often dis...

Self-stigma is highly prevalent in serious mental illness (SMI) and is associated with poorer clinical and functional outcomes. Narrative enhancement and cognitive therapy (NECT) is a group-based intervention combining psychoeducation, cognitive restructuring and story-telling exercises to reduce self-stigma and its impact on recovery-related outco...

Social dysfunctions (SD) are frequently observed in subjects with schizophrenia. Some of these dysfunctions are also observed in other neuropsychiatric disorders such as autism spectrum disorders (ASD), major depression, bipolar disorder, or Alzheimer disease. Recently, a characterization of a specific type of SD in schizophrenia has been proposed,...

This paper explores the potential of recent research on metacognition to offer new avenues to assess and address the phenomenon of fragmentation in schizophrenia, which was described by E.Bleuler as «splitting». The concepts of metacognition characterize and quantify alterations or decrements in the processes by which fragments or pieces of informa...

The experience of psychosis often involves subtle but pervasive changes in how persons experience themselves and the world. On the other side of the coin, persons also recover from psychosis and these subtle changes are reversed. Metacognitive reflection and insight therapy (MERIT) is an example of one attempt to develop a recovery oriented therapy...

Borderline personality disorder (BPD) is characterized by intense emotions, self-harm, unstable self-image, and risky behaviors, which impede wellness and interfere with occupational participation. However, literature on occupational participation of people with BPD is scarce and has mostly focused on women. This study explores and elucidates inter...

Similar to trends in Europe, approaches to mental illness in colonial America and recorded in early United States history were commonly characterized by incarceration and the removal of individuals from communities. In the mid-20 th century, a major shift began in which treatment was offered in the community with the aim of encouraging individuals...

Psychoanalysis has produced important theories that help explain the radical alterations in self-experience central for persons experiencing psychosis. These concepts have led to important clinical developments, case studies, and some research on the efficacy of psychodynamic psychotherapy for psychosis (Gottdiener, 2006). However, psychodynamic ps...