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Supervision in the Psychotherapy of Schizophrenia: Awareness of and Mutual Reflection upon Fragmentation



Historical and newly emerging models of schizophrenia suggest it is a disorder characterized by the fragmentation of the experience of the self and the world, leading to the interruption of how a unique life is unfolding in the world. It has been proposed that psychotherapy might therefore promote recovery by facilitating the development of a greater ability to integrate information about the self and others. In this paper we explore how the supervision of a metacognitively-oriented psychotherapy can assist therapists to experience and conceptualize fragmentation within sessions, join patients in the gradual process of making sense of their psychiatric problems and life challenges, and ultimately envision and achieve recovery. Common challenges and responses within supervision are described and discussed.
Paul H. Lysaker
, Kelly D. Buck
, Michelle L. Pattison
Rhianna E. Beasley
, Jaclyn D. Hillis
and Jay A. Hamm
Historical and newly emerging models of schizophrenia suggest it is a disorder characterized by
the fragmentation of the experience of the self and the world, leading to the interruption of how
a unique life is unfolding in the world. It has been proposed that psychotherapy might therefore
promote recovery by facilitating the development of a greater ability to integrate information
about the self and others. In this paper we explore how the supervision of a metacognitively-
oriented psychotherapy can assist therapists to experience and conceptualize fragmentation
within sessions, join patients in the gradual process of making sense of their psychiatric
problems and life challenges, and ultimately envision and achieve recovery. Common chal-
lenges and responses within supervision are described and discussed.
KEY WORDS: schizophrenia; psychosis; supervision; psychotherapy; metacognition;
Paul H. Lysaker, PhD, Richard L Roudebush VA Medical Center, Indianapolis IN; Department
of Psychiatry, Indiana University School of Medicine, Indianapolis IN, USA.
Kelly D. Buck, PMHCNS-BC, Richard L Roudebush VA Medical Center, Indianapolis IN.
Michelle L. Pattison, MA, School of Psychological Sciences, University of Indianapolis,
Indianapolis IN.
Rhianna E. Beasley, MA, School of Psychological Sciences, University of Indianapolis,
Indianapolis IN.
Jaclyn D. Hillis, PsyD, Chillicothe VA Medical Center, Chillicothe OH.
Jay A. Hamm, PsyD, Midtown Community Mental Health, Indianapolis IN.
Address correspondence to: Paul H. Lysaker, PhD, Richard Roudebush VA Medical Center
116a, 1481 West 10
St., Indianapolis IN 46202, USA. Email:
The American Journal of Psychoanalysis, 2019, 79, (284–303)
2019 Association for the Advancement of Psychoanalysis 0002-9548/19
The psychiatric conditions now referred to as schizophrenia spectrum
disorders have often been suggested to reflect the kinds of processes which
are not accessible or responsive to psychosocial interventions. For example,
in the view of Kraepelin (1919) and others (Falkai et al,2015), these
conditions reflect a biological disturbance, most likely metabolic in nature.
These basic disturbances then lead to the loss of volition, drive, and affect
(Noll, 2011) which would not be amenable to psychosocial interventions
including psychotherapy.
In contrast to Kraepelinean and neo-Kraepelinean views, there are other
views which comprehensively describe the challenges of schizophrenia but
link it with phenomena which could be addressed by psychosocial
treatments including psychotherapy. Most popular among these are the
views of Bleuler (1911) and others (Hamm et al,2017) which suggest that
schizophrenia develops around the fragmentation of self-experience
(Katschnig, 2016). Rather than involving a direct pathway from biological
disturbance to psychosocial disturbance, Bleuler proposed that schizophre-
nia reflects a process in which patients’ lives are interrupted by the
fragmentation of previously integrated psychological processes (Maatz et al,
2015). Working with Jung, Bleuler (1911) concretely proposed that in the
conditions he labeled the schizophrenias, persons experience diminished
abilities to coherently link ideas, emotional experience and desires together.
He referred to these respectively as disturbances in associations, affects and
ambivalence. As a result of each of these losses Bleuler observed that there
necessarily followed the collapse of basic goal-directed activity and
connection with the world, which he referred to as autism.
Historically it is important to note that Bleuler was influenced by Freud
and his models of psychosis, which also emphasized phenomena which
could hypothetically be the focus of psychosocial treatment. These included
the unbinding of thoughts and affect as well as gross withdrawal from the
world (Freud, 1914,1915). Indeed, following Freud’s writing, psychoana-
lytic work exploring the issue of fragmentation within schizophrenia
continued. Some work, for example, has sought to pinpoint the loss of a
larger sense of the self and others as occurring at the level of boundary
disturbances between objects in the world (Federn, 1926) or during the
process of symbolization (Arieti, 1955). In his discussion of narcissism as
fragmentation, Kohut (1971) described psychosis as an even more profound
collapse of the connection between individual bodily and mental activities,
one which was so extreme that it rendered mental experiences ‘‘pre-
psychological’’ (p. 30). Bion (1959) and Winnicott (1963) have explored
these ideas, examining how fragmentation may occur as a means of
protecting a rudimentary sense of self that is threatened by both its own
experiences of the world and the experience of what the world provokes
within it. Others have proposed that internal experience may become
fragmented as a result of defective processing of experiences, including
those with early caretakers (Wexler, 1971). More recent work (Gurevich,
2014) reveals continued interest in fragmentation, including the role of
external trauma in its emergence.
Seeking to unify psychoanalytic theory about the fragmentation of self-
experience and schizophrenia, Grotstein (1977) has proposed that there
may be different pathways to fragmentation. Specifically, psychosis is
suggested to emerge as a result of the lack of stimulus barrier or a
heightened sensitivity to stimulus. For Grotstein, either process can make
persons vulnerable to experiences, wishes and impulses which threaten the
existence of the self, and the only recourse is to derail thought processes in
general such that persons are no longer able to form integrated ideas about
themselves which might be understood by others. Following up on this,
Ogden (1980) has proposed an even broader model in which fragmentation
creates a state of non-being in which tensions exist as to whether any sense
or meaning at all will be assigned to experience. Acknowledging the
possibility that fragmentation could be primarily a result of any of a number
of factors, Frosch (1983) has noted how nevertheless, the end result of
fragmentation is the experience of the self as tenuous and on the edge of
destruction, and hence is both a source of dysfunction as well as pain.
As noted above, for the field of psychotherapy, these theoretical issues
are of core importance since they suggest a potential role for psychotherapy.
If fragmentation in self-experience is a central aspect of schizophrenia, then
naturally questions arise regarding whether and how psychotherapy might
treat the experience of fragmentation. Certainly, if a form of psychotherapy
could treat fragmentation directly, then it would have the potential to help
persons with schizophrenia regain the ability to coherently link thoughts
together, make sense of affects, sort out wishes and needs, and ultimately,
decide how to find a way to a satisfying life. This is consistent with a long
history of psychodynamic psychotherapy of schizophrenia which can be
seen as seeking to promote the coherence of internalized representations of
self and others, and their relationships to one another (Searles, 1965).
One response to these questions has been the proposal by metacogni-
tively-oriented researchers that psychotherapy might help resolve fragmen-
tation by addressing how persons notice discrete pieces of information, how
they integrate or bind those pieces of information together to promote a
sense of self and others, and ultimately, how they then use that available
information to understand and address emergent challenges in life (Lysaker
and Klion, 2017; Lysaker et al,2019). This work has used the term
metacognition to refer to a spectrum of activities which enable persons to
have a cohesive sense of self and others available within the flow of life
(Lysaker et al,2018a,b) and the concept of deficits in metacognitive capacity
to operationalize the processes which characterize fragmentation. This work
has relied on a new methodology to document the presence and influence of
the fragmentation experience in schizophrenia (Hamm and Lysaker, 2016;
Lysaker et al,2018b), to conceptualize the disruption in metacognitive
capacity as a treatment target, and at a finer level of analysis, to use
interventions that directly promote the integration of complex ideas about the
self, others, and one’s larger community (Lysaker et al,2018). This form of
psychotherapy, Metacognitive Reflection and Insight Therapy (MERIT)
(Lysaker and Klion, 2017), has shown initial promise promoting integration
and wellness in two randomized trials (de Jong et al,2018; Vohs and
Leonhardt et al,2018) two open trials (Bargenquast and Sweitzer, 2014;de
Jong et al,2016), two qualitative studies (de Jong et al,2019; Lysaker et al,
2015), and multiple detailed case studies (c.f. Hamm and Lysaker, 2018).
One challenge to the implementation of MERIT and related practices that
focus on integration in psychotherapy concerns the need for therapists to
shift their focus away from content and instead to how persons are
assembling information about themselves and others (Hamm et al,2016). In
particular, this may require activities that run counter to current psy-
chotherapy training trends and pose challenges for which many psy-
chotherapists may be unprepared. In this paper, we will examine two
specific challenges: awareness of the experience of fragmentation and the
development of a mutual reflection upon fragmentation as a means to
address it. While there is clear overlap between these challenges, we think
of the first as more pertaining to awareness of fragmentation itself and the
second to the processes which lead to its resolution. For each of these
challenges, we will describe the dilemmas posed for the therapist and the
psychotherapy, and then focus on supervisory responses that may assist
psychotherapists in effectively responding to and treating fragmentation in
adults diagnosed with schizophrenia. Finally, we will discuss broader
implications of these issues that tend to arise during the supervision of
psychotherapy and other services that address recovery from complex
mental health conditions.
Of note, in discussing psychotherapy supervision we will be focused on
our experiences and reflections about the supervision of MERIT. However,
we suggest that these supervisory processes are applicable to a broader class
of integrative, humanistic and psychodynamic psychotherapies which may
ultimately promote health by helping persons make sense of their
experiences and challenges and decide upon an adaptive course of action.
We are also focusing explicitly on recovery as an outcome from
schizophrenia. As reviewed elsewhere (Leonhardt et al,2017), the recovery
model stresses that schizophrenia is not a condition with a uniform outcome
involving progressive deterioration. Instead, the attainment of wellness in a
manner that is personally meaningful and acceptable to patients is a
reachable outcome and should be the goal of treatment.
Approaching fragmentation as a phenomenon to be perceived and understood
The first challenge we propose that therapists and supervisors face when
working with people who experience fragmentation is the need for the
therapist to conceptualize and recognize the experience of that fragmen-
tation itself. Patients do not generally express to the therapist that their
experience is fragmented. They do not directly report that their thoughts,
emotions, and basic needs lack integration. Fragmentation is not something
similar to a medical symptom which appeared one day. Instead, fragmen-
tation is something for the therapist and patient to jointly perceive as
patients talk about their lives.
The fragmentation of a sense of self in schizophrenia has been described
using many different metaphors, including Kraepelin’s orchestra without a
conductor. From a metacognitive view, however, we have recently suggested
that rather than the loss of a conductor ‘‘directing a scored ensemble,’
fragmentation represents the absence of ‘‘an arranger, who sometimes
improvisationally, sometimes habitually, locates possibilities in parts of what
metacognition accessesintersubjectively framed experiences of self-world
interactions’’ (Lysaker et al,2018b, p. 166). Concretely, this can appear in
many forms including monological, barren, or cacophonous presentations of
the patient’s experience, or any combination of those presentations.
Recognition of fragmentation in each of these states represents awareness
of discrete and often relatively simple atomistic aspects of experience that are
not connected to other aspects of experience in a meaningful manner. In a
monological presentation, for example, a person might be aware of a single
theme of experience, such as feeling persecuted or unappreciated, but fail to
meaningfully integrate other aspects of experiences to form a complex and
cohesive understanding of that single theme. In a barren presentation, for
example, there may be only small pieces of experience, such as an awareness
of having no thoughts, which—like a monological presentation—is not
integrated into any larger sense of self or others.
The natural challenge here for therapists is to be able to see the absence
of integration as patients describe their experience. To do so, it would seem
that therapists must have the awareness of their own integration of
experience, something which generally happens automatically and
instantly, and then imagine what would happen if they could not integrate
information. In supervision, we have used the following illustration to help
therapists grasp the idea of automatic integration and what would happen if
it failed. In this illustration we ask the therapist to imagine themselves or
someone else attending a lecture. A person with intact metacognitive
capacity may realize and simultaneously understand their experiences of
incessant foot tapping, warmth in their face, preoccupation with their
grocery list, and a wish to leave the room as reflecting something larger,
such as being angry with something said in the lecture. There might even be
a broader, more complex thought such as a similarity between being angry
about this issue during the lecture and other things that anger the person in
other situations, perhaps leading to a realization that their anger is
exaggerated and should not be expressed.
With this example we hope in supervision to help the therapist realize
how instantly a broader and nuanced sense of oneself appears and how it
informs action. The next step is to think about what happens if a person
experiences incessant foot tapping, warmth in their face, preoccupation
with their grocery list, and a wish to leave the room but is unable to see how
those experiences are connected, something that may parallel Bleuler’s
original ideas about the fragmentation of experience. Commonly, therapists
can then imagine how they, the therapist, might feel disoriented, for
example, if they could notice but not understand their foot tapping, warmth
in their face, and preoccupation with seemingly irrelevant thoughts, thereby
forming a more embodied understanding of fragmentation.
Returning to the task of the therapist to accurately perceive the degree to
which patients experience fragmentation, we are in the broadest sense
calling for supervision to support therapists in making accurate assessments.
At issue in supervision is whether the therapist has overestimated or
underestimated the degree of integration of which the patient is capable,
and therefore, is not accurately perceiving the patient’s experience of
This has requirements that go beyond didactic training in assessment,
however. It requires ongoing reflection within supervision about biases and
reactions that can affect assessment and understanding of fragmentation.
Foremost, supervision must implicitly and explicitly assist therapists to think
about their own metacognitive processes as they think about the patient.
How have they integrated the information the patient has shared, and have
they formed an understanding of the patient’s experience of themselves and
others? Then, how well does that picture match the patient’s behavior?
Thus, supervision provides a kind of parallel process (McNeill and Worthen,
1989; Mothersole, 1999) in which there is ongoing reflection about
therapists’ reflections.
At the risk of creating a false dichotomy, we have observed that when
supervision takes on the question of how the therapist is integrating
information, we find therapists are likely facing two different types of
problematic responses. In the first problematic response, the therapist, as a
matter of habit, has overestimated patients’ degree of integration because he
or she has automatically filled in information or perceived integration when
it was not happening within the patient. This is consistent with a well-
documented finding from visual perception research that persons fill in
missing information when presented with images of incomplete objects
(Gregory, 1977). In a similar manner, therapists may automatically sense
that patients are having more integrated experiences because they, the
therapist, have connected the fragments together and possibly have done so
without even being aware of it.
To illustrate this issue, consider that the patient is the person at the
lecture with incessant foot tapping, warmth in their face, preoccupation
with their grocery list, and a wish to leave the room. A therapist may
assume that the patient can readily see he or she was angry because the
therapist can see these signals in his or her life and in the lives of others.
The therapist may then repeatedly ask the patient for emotions he or she
felt and suggest to the patient that he or she was angry until the patient
agrees with them. The idea that the patient was angry and aware of it
might relieve therapist anxiety that can often emerge when experiencing
fragmentation. In other words, the call for such agreement from the patient
might stem from the therapist’s wish to connect the fragments to ward off
his or her own discomfort when facing uncertainty and novel experiences.
Thus, that reduction in anxiety could be perceived by the therapist as
direct evidence of the correctness of their view that the patient was indeed
aware of their anger, which in turn could help restore the therapist’s sense
of personal adequacy. Another therapist might interpret the lack of
expressed emotion itself as a reflection of a lack of motivation and
similarly grossly fail to appreciate how the patient’s inability to piece
together aspects of their experiences into more complex ideas may be
contributing to the absence of behaviors. This assumption might relate to
previously held ideas that a barren state or disorganized thoughts are
symptoms that should be targeted first, rather than seeing these experi-
ences as likely reflecting fragmentation of psychological processes that can
be understood as potentially meaningful and addressed by promoting
A second problematic response stems not from automatically filling in
information and missing fragmentation, but from therapists finding it painful
or disorienting to accurately perceive fragmentation. It may be painful for
therapists to see the suffering inherent in fragmentation. Seeing a patient in
such great pain may also leave the therapist feeling powerless and
vulnerable. The fragmentation of the patient may also be disorienting to
the therapist, making them feel as if their own metacognitive capacities are
failing. These difficulties may be particularly pronounced for new therapists
who are striving to master newfound psychotherapy skills, yearning for
structure within psychotherapy to alleviate anxiety, or struggling with their
own feelings of inadequacy and confusion. All of these may motivate the
therapist to see more integration than exists to escape from their own
As an illustration of this, continuing with the example of the patient
talking about what happened at the lecture, perhaps the initial experience
of the patient’s fragmentation was disorienting for the therapist. Sitting
with the patient who couldn’t see the same meaning structures as the
therapist did may have led to the fragmentation of the therapist’s own
experience. Concretely, facing the patient who could not link together
experiences into a sense of self and others, the therapist may have felt
confused about what was being asked of him or her, resulting in a feeling
of being inadequate which could be alleviated if the patient was seen as
less fragmented.
Importantly, an entirely different and equally problematic solution may
also occur. Therapists who react adversely to patient fragmentation may find
it a relief instead to assume that there is no meaningful mental activity going
on and hence no suffering. An example of this could be the therapist who
equates fragmentation with cognitive impairments and so treats their
patients as unable to benefit from a reflective form of psychotherapy. In our
experience, the therapist in this scenario may often postpone psychotherapy
or suggest neurocognitive testing to establish whether the patient is
‘appropriate’’ for psychotherapy. At the phenomenological level, the
therapist here may, in error, interpret fragmentation as the absence of
In response to these problematic responses—the false perception of
integration or negative reactions to perceived fragmentation—the supervi-
sion process is likely to be the same. There is a need to help therapists see
the fragments of the patient’s experience, suspend any automatic tendency
or wish to connect the fragments, and explore reactions to patients’
fragmented experience of themselves. In taped supervision, this could
involve identifying tracts of texts which express fragments of experience that
can be first considered on their own and then later seen as connected with
some degree of integration. The timing and content of therapist interven-
tions can also be considered as a potential reflection of their responses to
fragmentation. For example, trying to cheer a patient up or smooth over a
disagreement could be seen as a reflection of the therapist’s discomfort with
fragmentation, as could a therapist avoiding affect-laden topics.
Helping therapists both to correctly perceive fragmentation and to
understand how they came to mistake fragmentation for either something
more integrated or as irrelevant experience may call for normalization of
therapists’ feelings of fragmentation, confusion, or anxiety. It may require
supervisors to disclose their own experiences of fragmentation and
discomfort with uncertainty. They may frame for therapists how they have
developed ideas about the ‘‘short cuts’’ they take to understanding others
and personally relevant clues or hints that come up when they are taking
those short cuts, spurring therapists to do the same.
In our experience, this process often involves several twists. First,
therapists may feel they are ‘‘breaking’’ rules that preclude persons in most
social situations from perceiving undesirable pieces of one another. Many
therapists trained contemporaneously may have felt urged in previous
training to suspend judgments about others and so feel ethically prohibited
from knowing aspects or fragments of patients (or themselves) which are
not prosocial and might be perceived as selfish, aggressive, or egocentric.
For example, a therapist may feel it is wrong to notice the fragments of
experience related to sexuality and rage in the patient who deny these
feelings and instead parrots material from psychoeducation about their
need for medication. Other therapists may also have had previous training
and professional experience in which their own anxiety and pain was seen
as a sign of ill health and something to be denied as quickly as possible. In
previous unfortunate experiences, therapists’ awareness of their anxiety or
anger in the face of a patient may have been dealt with in supervision not
as an important clue about the therapy in question but as a treatment need
of the therapist. It may thus be necessary in supervision to acknowledge
how different and challenging this approach may be for the therapist. It
may be essential for therapist frustration and anger with the supervisor for
their attention to these details to be acknowledged, again in a matter of
parallel processes that promote reflectivity. As long noted by others
(Searles, 1965), supervisors might need to be aware of their own
competitiveness with therapists, as well as their needs for certainty and
therapist approval. Thus, in another parallel process supervisors may need
to be aware of these reactions on their part and move beyond those to
allow the therapist to have their own unique and possibly surprising
reactions to the supervisor.
Understanding that fragmentation is resolved as meaning is jointly made
in psychotherapy
While the first challenge we identified for therapists pertained to the need to
perceive fragmentation itself, the second concerns the need to understand
how fragmentation can be resolved in psychotherapy, which is only through
joint reflection. Considered as a fundamental aspect of human conscious-
ness, all of us need the presence or potential presence of another mind to
piece together experience and decide what it means (Hasson-Ohayon et al,
2017). The broader senses we evolve of ourselves that move beyond
specific experiences are dialogical. Put more simply, meaning making is
intersubjective (Stern, 1985; Yerushalmi, 2012). Even when we draw private
conclusions about ourselves or others, those ideas are always created with
someone to whom they might be addressed, whether that person is a real
person, someone we remember, or someone we imagine we might
encounter in the future. This is to say that the way we connect what we
experience into larger meaningful phenomena are neither things we do in
isolation nor are they the result of conclusions which others supply us.
One implication of this for therapists who have come to perceive
patients’ fragmentation is that integration can only be promoted by joining
with patients and thinking together about the experience of those fragments
(Buck et al,2015). It is here where we see the second general issue for
supervision. At both an epistemic and ontological level, how are therapists
inclined to respond to their awareness of patients’ fragmentation? At the
therapist level, how does the therapist choose immediately and automat-
ically to promote integration in therapy and develop a process of joint
reflection with patients about their experience?
The therapist’s task is to think with patients about the fragments of their
experience and how the patient is or is not integrating those experiences.
This requires several activities including that therapists remain focused on
the task of joint integration and do not assume the task of primarily coming
up with solutions on their own and then sharing them, no matter how clever
those solutions may appear. Thoughts and experiences should be fluidly
shared and considered in a way that matches patients’ capacities for
integration or metacognition (Lysaker et al,2011). The therapist and
supervisor may conceptualize the patient’s dilemmas by analogy as similar
to those of the calculus student for whom the problem is that they don’t
know how to solve the specific calculus problem, not that they simply don’t
know the answer to a specific problem. Following that framing, the therapist
may need to help the patient do more than just find the right answer to the
specific problem. Patients facing fragmentation need someone to join them
and begin by helping them reflect upon the pieces of their experiences, and
then explore how they might slowly integrate those pieces. For example, in
the illustration of the patient attending the lecture, the MERIT therapist
would try to understand with the patient the many different fragments the
patient was experiencing and to jointly know that the patient experiences
many different things which they struggle to see as related. This is consistent
with the view that can be found in person-centered approaches that frame
recovery from serious mental illness as a matter of ‘‘co-construction’
(Korsbek, 2016).
When this is successful, therapists should be able to name different
fragments expressed by patients without offering complex connections
between them that could exceed patients’ metacognitive capacities.
Supervision then can support this in several ways. For one, therapists may
think through and better see the distinctions between different fragments
that have emerged in a given session. With those fragments successfully
separated in their mind, they might in supervision hypothesize different
ways that those fragments might be connected. In the manner of parallel
process, the supervisor and therapist might jointly think about what the
fragments could mean in terms of their larger relationships to one another.
For example, consider the patient who discussed (over the course of one
session) abandonment by a parent, the disappearance of a sister, an
aggressive verbal attack on a neighbor, recent drug use, gross lack of
activity, eating a large lunch, and then wanting to reduce frequency of
sessions. Supervision might support reflection about these individually but
then think about how these fragments might come to be assembled by the
patient and therapist later as reflections of a larger experience of the
tenuousness of relationships, confusion about interpersonal connections,
and potentially that the end of every session is painful for the patient (e.g., it
is something good that abruptly ends, leaving the patient bereft).
Beyond the consideration of the fragments themselves which patients
present, supervision can also explore therapists’ experiences of encounter-
ing fragments and not connecting them. There may indeed be common
experiences here between therapists. As is well documented, when human
beings experience the fragmentation of another, we may readily fear our
own fragmentation or the loss of our ability to integrate information (Searles,
1965). Supervision can support therapists here by disclosing supervisors’
similar reactions. Naming and normalizing these experiences can further
diffuse their power to create disruptive levels of anxiety in the therapist.
When experiencing fragments that the therapist does know how to connect
to one another, therapists may also not so much react negatively but be
willing to doubt themselves or feel confused.
For example, when aggressive aspects of the patient emerge, some
therapists may find them aversive when they realize that if they met those
aspects in other people in their lives, they would hold them in disdain.
Following the same pattern, when encountering fearful aspects of the self of
a patient who genuinely finds safety in inactivity and withdrawal, other
therapists may again be uncomfortable when they realize they would avoid
someone who acted this way in their own lives. They might also become
fearful the patient will always remain stuck without clear goals to become
healthier like people they have known, and again this may lead them to feel
significant self-doubt and hopelessness. Thus, supervision can support
therapists by helping them identify themes they respond strongly to, see that
patients are composed of many facets or fragments of self-experience, and
expect a dynamic interplay among them which may culminate in
movements towards health.
When therapists are not joining patients and exploring their experiences
in ways that match patients’ metacognitive capacity, this can be apparent
from therapists who either cannot name distinct fragments or who ‘chunk’
sessions in larger themes, and hence, see only a larger incoherent whole
(i.e., not its constituent parts unrelated as they may be). In other words, it
should be apparent in supervision that the therapist is not considering the
patients’ fragments of self-experience as potentially independent of one
another. It can also be reflected in language in which therapists acknowl-
edge that they are to ‘‘trying to get’’ the patient to do or think something, or
prescribing them activities which they believe will relieve fragmentation.
Those activities could be sensible and well-meaning when considered on
their own. For example, a therapist who is compelled to fix the fragmen-
tation might refer the patient to an expressive therapy class, mindfulness, or
dance therapy.
Here supervision may take any number of routes depending on the extent
to which this is a reaction to specific content or whether it reflects a larger
epistemic stance on the part of the therapist. In beginning therapists who
have a basic stance that impedes joining and reflecting upon fragments of
experience, this can reflect a need to ‘‘fix’’ patients before getting to know
them. This goal of fixing may be a reflection of a professional identity, but it
may also be an aspect of stigmatizing views of patients in which persons
with psychotic disorders are mistakenly seen as unable to manage their own
lives and require the kind of benevolent care afforded to persons with severe
neurocognitive disorders (Buck and Lysaker, 2010). As noted above but also
described elsewhere (Hamm et al,2016), supervision can help therapists
realize that their basic assumptions and embodied responses to fragmen-
tation are inaccurate or unhelpful. For instance, it may reveal stances taken
by the therapist in which they are most comfortable when telling patients
about reality, encouraging healthy behavior, advocating for patients, or
soothing patients’ discomfort. Supervision may therefore have to directly
address both unhelpful and stigmatizing stances before fragmentation can
be meaningfully discussed. This could include frank discussion about
stigma as well as the pressures that come from our institutions and traditions
that make it easy to take on an expert or caring role, both of which are easily
tainted by stigma that compromises the potential for genuine dialogue.
Supervision help therapists to appreciate the relief that may come from
the joint understanding of fragments of experience. In other words,
supervision can help therapists see how a shared understanding of a
fragment of experience may be no less powerful than a shared understand-
ing of a complex idea about oneself or others. Certainly, a shared
understanding of any kind of fragmented experience requires the presence
of a therapist as someone relating to the dilemmas as part of the human
condition. Of note, some therapists may neglect the idea of joining because
they have a general assumption that the patient is already someone the
therapist understands and knows. This may appear in the form of
assumptions from the therapist that the patient is a mirror of how they,
the therapist, generally understands others.
Beyond issues of stigma or wanting to ‘‘fix,’’ it may also be discovered in
supervision that therapists are not joining the patient because they
fundamentally view fragmentation as dangerous and something that could
not be jointly understood, and therefore, something to be made whole first.
Since within this view joint meaning making is not possible, therapists may
think they can only ‘‘fix’’ fragmentation by sharing information with the
patient or prescribing healing activities to them. This stance that fragmen-
tation cannot be mutually understood can be potentially rooted in or
reinforced by some phenomenological accounts of psychosis which posit
these experiences as outside of understanding (Sass, 2013). This stance may
be underneath the surface as therapists simply try to explain something to a
patient about the patient’s experience, or it can manifest as therapists try to
teach patients their theories.
Supervision here may help the therapist name this stance and think about
both its origins and potential lack of utility, perhaps again through use of
analogy (e.g., the calculus student). Supervision can also actively challenge
preemptive assumptions by therapists that they ‘‘know’’ the patient on the
basis of having already ‘‘taken their history.’’ Supervision can gently
challenge shallow or premature understanding of patients by thinking about
any number of fragments of self-experience that have emerged but have
already been forgotten by the therapist. It can also easily challenge, through
simple joint reflective activities with therapists, any notion that patient
verbalizations do not communicate anything. Thus, it can assist therapists to
recognize pain often not readily obvious in more disorganized forms of
speech. For example, the patient who appears preoccupied with grandiose
aspects of the self might experience a deep sense of inadequacy. In this
example, the supervisor might encourage the therapist to reflect on their
own experiences of feeling inadequate and corresponding desires to engage
in grandiose thought or activity to alleviate such feelings.
The failure to join with patients may also occur when certain themes
emerge or threaten to emerge within a session. This could include
aggressive or sexual themes which emerge when certain fragments of self-
experience are activated. Other themes that can trigger therapists to
disengage from an intersubjective experience can include severe inertia on
the part of the patient or jealousy of the therapist, which may be tied directly
to patient awareness of the real-world inequity (e.g. financial/social
privileges, disparities in exposure to trauma, or injustice) and which the
therapist may be uncomfortable bringing into their awareness. Failure to
join the patient might be represented by therapists’ tendency to want to
conduct repetitive risk assessments when aggressive themes emerge, insist
the patient is aware of his or her own thoughts when experiencing severe
inertia, or communicate to the patient or supervisor that the therapist is an
advocate for social justice. Turning to the broader issue of supervision,
again in the manner of parallel process, while the supervisor might feel
urged to ‘‘get’’ the supervisee to ‘‘stop’’ doing something or to ‘‘start doing’
something else when they are not joining the patient, the supervisor must
instead understand how to join the therapist. The task is not to ‘‘fix’’ the
supervisee’s underlying assumptions and basic responses but to promote
joint awareness and reflections about those.
While therapists may readily master how to respond to fragments
characterized by common human emotions, such as fear, sadness, and
anxiety, there may be more difficulty when the fragmented experience of
patients involves increasingly anomalous experiences such as thought
insertion, socially unacceptable content (e.g., vividly aggressive or sexual
ideation), or profoundly barren states in which patients report no thoughts or
emotions. Nevertheless, the task is the same for the therapist and also for the
supervisor regardless of the experience if it is to be a subject of joint
reflection. The experience of thought disorder could, for example, be
related to times the therapist has felt urges or had wishes that were
completely ego dystonic, and it might have been comforting to see them as
coming from outside the self. Vivid aggressive images could be recognized
by linking them to an experience of road rage while severe emptiness could
be related to by thinking about a time during significant grief or mourning
when the therapist was exhausted and truly felt he or she had nothing to say
to others.
Of note, the process of joining the patient and thinking together about the
experience of the fragments of themselves is fundamentally a dialogical
task, and in this regard, it is inevitable and necessary that therapists have
different thoughts from their patients and supervisors. In other words, in
addition to thoughts that complement the patient’s thoughts, the therapist is
likely to have thoughts that are either unrelated to or contradict the thoughts
of the patient and supervisor. This may include instances wherein therapists
have ideas that seem incompatible with previous training. For example, a
therapist might fear that if they acknowledge the rageful aspect of a patient
that they will somehow affirm the stigmatizing view that mental illness
means dangerousness, which may conflict with their desire to advocate
against social injustice and stigma experienced by people with serious
mental illness. Likewise, they might fear that noticing a poor choice on the
part of the patient might similarly affirm the stigmatizing belief that mental
illness means incompetence or that challenging a patient’s view of
themselves may further invalidate a weak sense of self. Here supervision
may effectively rely on self-disclosure on the part of the supervisor to help
therapists see that we all have aspects of ourselves which are less competent
or disagreeable, and we are always in a fluid dialogue with others about
who we are. This kind of dialogue promotes the larger notion that ultimately
a full life does not necessarily come from pretending that unwanted or
unpleasant parts of the self do not exist.
For some therapists, however, even more basic supervision may be
necessary. Some therapists have largely experienced previous training
emphasizing only what the therapist does but not why or how they do it. It
may have been assumed, following a line from the poet Gertrude Stein that
a ‘‘Rose is a rose is a rose is a rose,’’ that an intervention is an intervention is
an intervention. In previous training, human suffering may have been
treated as a discrete set of categories which can be plainly reported and
identified by any human being and for which a series of proven solutions are
available to the willing therapist and patient. Similarly, certain interventions
may have been previously conceptualized without reference to patients’
metacognitive capacity. In supervision, then, a task for supervisors is to
think with therapists about their practice, and how an intervention
supplying meaning is not the same as an intervention in which meaning
is made jointly when addressing fragmentation, even if each reaches the
same conclusions.
In this paper, we explored two major nuances of supervision meant to assist
therapists to respond to the fragmentation of self-experience in patients with
schizophrenia spectrum disorders. We have discussed specifically how
supervision can support therapists to be able to genuinely notice and
appreciate the experience of fragmentation, and ultimately to join patients
and share in that experience and begin to make meaning of it. We have
discussed how this may call for examination of therapists’ basic experience
of, fundamental beliefs about, and automatic responses to fragmentation. It
is hoped that our exploration of these issues will support the development
and implementation of these methods more broadly over time.
This work, though, is only a beginning, and there are other complex
issues involved in this form of supervision for which there is not sufficient
space to explore here. These include how supervision can help therapists
respond to slow and uneven progress, understand breaks in therapy, and use
self-disclosure, as well as to explore how integration and increased
awareness might breed pain (Buck et al,2013). There are also other more
specific techniques that may assist therapists in understanding the experi-
ence of fragmentation and subsequent recovery, including the use of
literature in group supervision (Hamm et al,2014; Leonhardt et al,2015).
Many empirical questions remain as well, including how the therapeutic
alliance should unfold in this kind of work. Further, what are the subjective
experiences of the therapist within supervision? How does this work affect
how therapists think about themselves and their professional work more
broadly? Answers to these questions are needed to help understand what
kinds of therapists are best suited for this work and could benefit from these
kinds of supervision.
1. Paul H. Lysaker, Ph.D., is a clinical psychologist at the Richard L Roudebush VA Medical
Center and a Professor of Clinical Psychology in the Department of Psychiatry at the
Indiana University School of Medicine. He is an author of over 450 papers published in
peer reviewed journals. His current research interests include the metacognitive,
phenomenology and psychotherapy for psychosis in adults.
2. Kelly D. Buck, PMHCNS-BC, is a clinical nurse specialist at the Richard L Roudebush VA
Medical Center. She is an author of over 50 papers published in peer reviewed journals.
Her current research interests include the metacognitive, recovery and psychotherapy for
psychosis in adults.
3. Michelle L. Pattison, M.A., is a doctoral student at the University of Indianapolis. Her
research interests include understanding ways in which self-reflection occurs in a SMI
population throughout the course of therapy, stigma, and recovery-oriented care. Previous
research has focused on insight, double stigma, and the promotion of recovery through
utilizing Metacognitive Reflection and Insight Therapy (MERIT).
4. Rhianna E. Beasley, M. A., is a doctoral student in clinical psychology at the University of
Indianapolis. She is currently a trainee in the Psychosocial Rehabilitation and Recovery
Center (PRRC) at the Roudebush VA Medical Center, and has had previous training in
private practice and community mental health. Her research interests include the
psychotherapy of serious mental illness, and the intersection of psychosis and trauma.
5. Jaclyn D. Hillis, Psy. D., is a clinical psychologist at the Chillicothe VA Medical Center.
She currently provides and supervises MERIT informed psychotherapy for veterans with
prolonged and early psychosis. Her current interests include understanding the influence of
metacognitive growth on self-efficacy.
6. Jay A. Hamm, Psy.D., is a clinical psychologist at Eskenazi Health Midtown Community
Mental Health in Indianapolis, Indiana, USA and clinical assistant professor with Purdue
University, College of Pharmacy. He has published more than 40 peer-reviewed articles
and several book chapters on serious mental illness, psychosis, recovery-oriented
psychotherapy, and metacognition. His clinical work is focused on providing metacog-
nitive psychotherapy to adults diagnosed with serious mental illness and he actively
supervises clinical psychology trainees and community mental health staff.
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... Supervision of MERIT trainees emphasizes maintaining an open, consultative stance, prioritizing meaning-making over symptom-focused interventions, and tailoring interventions to appropriate metacognitive levels [10,15]. As noted elsewhere [16], MERIT's conceptualization of the spectrum of metacognitive ability ranging from states of fragmentation to integration has conceptual overlap with a number of psychoanalytic concepts related to psychosis (e.g. ...
... Modern conceptualizations of fragmentation revolve around difficulty integrating information about the self, others, and the world which impairs one's ability to establish and maintain a cohesive sense of self, identify and work towards goals, and resolve challenges in daily life [33]. Some writers have begun identifying reducing fragmentation and promoting integration as a core component of recovery [15,34]. ...
Full-text available
Recovery from schizophrenia and serious mental illnesses has been increasingly recognized as the expectation in mental health treatment. Recovery has been conceptualized as both objective and subjective, including symptom remission as well as movement toward integration and personal recovery, even in the face of persistent symptoms. Individuals with serious mental illnesses face a variety of stressors, notably including trauma, and as such, there is a need for more individualized, integrative therapy approaches to address these complex presentations. This paper presents a case illustration of an individual who experienced prominent psychosis and a history of repeated trauma, in order to demonstrate the use of an open, recovery-oriented psychotherapy approach. An outline of the integrative model utilized is offered, and themes of interpersonal processes, increased personal agency, attachment and transition, and fragmentation and integration are explored to support the idea that psychosis is a relatable and understandable human experience.
... The supervisee should also know that it is possible to contact or to return to the supervisor when in need of support or emotional modulation in problematic phases of the relationship with patients. Moreover, in order to promote supervisees' regulation of problematic emotions in the context of critical phases of their therapeutic relationships, supervisors should frequently disclose examples of one's moments of difficulty and vulnerability experienced in one's life or with one's patients and how they tried to master them reflecting upon one's emotions and asking for help (Lysaker, Buck, Pattison Beasley, Hillis, & Hamm, 2019;McWilliams, 2021). This lets the supervisee know that he/she can experience vulnerability without being considered weak or incompetent. ...
The term developmental trauma (DT) refers to the impact of stressful events which occur cumulatively within the child's relevant relationships and contexts, and usually early in life. According to several authors, DT depends on the caregiver’s inadequate intersubjective recognition of one or more aspects of the evolving individual’s identity. In the clinical and empirical literature, the study of therapists’ developmental trauma, and how it might constitute a relevant variable in the clinical exchange, seem to be underrepresented. In this paper, through the analysis of the supervision process of a clinical case, we show how the therapeutic relationship may implicitly take the form of a “dance” between the patient’s and therapist’s DT, that prevents the therapist from intersubjectively attuning with the patient; and how a supervision process peculiarly focused on the therapist’s DT can effectively promote this attunement and a good clinical outcome.
... The potential disintegration of links between bodily signals and mental processing is a common leitmotif across most theories of psychosis. From a psychotherapeutic perspective, Paul Lysaker and colleagues have developed a model of psychotherapy that is focused on metacognitive reflection, where metacognition constitutes a key psychological process sustaining the binding or integration of thoughts and feelings [37]. Their view is similar to the approach in MBT, where the disturbing and threatening nature of self-experiences in psychosis is emphasized, and the psychotic symptoms are seen to provide ultimate protection against loss of agency, affect, meaning, and self-coherence. ...
Mentalization-based treatment (MBT) for psychosis focuses on the decoupling of bodily and mental experience as well as the stresses of mentalizing during social interaction. In a framework of mentalizing, psychotic phenomena can be represented as severe disturbances to the experience of oneself as a coherent unit. Clinical treatment that aims to increase integration and stability of self-experience is illustrated in this chapter using clinical examples. The first task is to identify treatment objectives and define any obstacles to treatment, working with co-constructed representations of the clinical problem. The second task is to integrate the viewpoints of the patient, the clinical team, and the social care network, and to agree an overall working formulation. This is followed by therapeutic intervention to stabilize self-mentalizing using interventions from the core MBT model.
... A second aspect of MERIT supervision is that it should help therapists to join or share in the patient's experience of fragmentation before attempting to jointly make meaning of it. 30 This may call for supervisors to help therapists examine their basic experience of, automatic and visceral responses to, and fundamental beliefs about fragmentation. It has also been suggested that supervision should involve the identification and examination of counterproductive approaches that therapists may commonly take with individuals with psychosis, including declaring what is real and what is not, seeking to bestow knowledge or "facts" upon the patient, or seeking to reduce a patient's pain, this later stance often stemming from a therapist feeling overwhelmed. ...
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Recent research has suggested that recovery from psychosis is a complex process that involves recapturing a coherent sense of self and personal agency. This poses important challenges to existing treatment models. While current evidence-based practices are designed to ameliorate symptoms and skill deficits, they are less able to address issues of subjectivity and self-experience. In this paper, we present Metacognitive Insight and Reflection Therapy (MERIT), a treatment approach that is explicitly concerned with self-experience in psychosis. This approach uses the term metacognition to describe those cognitive processes that underpin self-experience and posits that addressing metacognitive deficits will aid persons diagnosed with psychosis in making sense of the challenges they face and deciding how to effectively manage them. This review will first explore the conceptualization of psychosis as the interruption of a life and how persons experience themselves, and then discuss in more depth the construct of metacognition. We will next examine the background, practices and evidence supporting MERIT. This will be followed by a discussion of how MERIT overlaps with other emerging treatments as well as how it differs. MERIT's capacity to engage patients who reject the idea that they have mental illness as well as cope with entrenched illness identities is highlighted. Finally, limitations and directions for future research are discussed.
... Current metacognitive approaches, like MERIT (Lysaker and Klion, 2017), already include facets of implicit work without fully conceptualizing it. A recent publication is compatible with psychodynamic practice as it pointed out the need to supervise (co)transference phenomena in response to fragmentation (Lysaker et al., 2019a). Working with co-and counter-transference has a long psychoanalytic tradition and particularities in response to psychotic states were elaborated and emphasized in modern approaches (Mentzos, 2015;Lempa et al., 2016). ...
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Synthetic metacognition is defined by integrative and contextualizing processes of discrete reflexive moments. These processes are supposed to be needed to meet intrapsychic as well as interpersonal challenges and to meaningfully include psychotic experience in a personal life narrative. A substantial body of evidence has linked this phenomenon to psychosocial functioning and treatment options were developed. The concept of synthetic metacognition, measured with the Metacognition Assessment Scale-Abbreviated (MAS-A), rises hope to bridge gaps between therapeutic orientations and shares valuable parallels to modern psychodynamic constructs, especially the ‘levels of structural integration’ of the Operationalized Psychodynamic Diagnosis (OPD-2). As theoretical distinctions remain, aim of this study was to compare the predictive value of both constructs with regard to psychosocial functioning of patients with non-affective psychoses, measured with the International Classification of Functioning, Disability and Health (MINI-ICF-APP). It was further explored if levels of structural integration (OPD-LSIA) would mediate the impact of metacognition (MAS- A) on function (MINI-ICF-APP). Expert ratings of synthetic metacognition (MAS-A), the OPD-2 ‘levels of structural integration’ axis (OPD-LSIA), psychosocial functioning (MINI-ICF-APP) and assessments of general cognition and symptoms were applied to 100 individuals with non-affective psychoses. Whereas both, MAS-A and OPD- LSIA, significantly predicted MINI-ICF-APP beyond cognition and symptoms, OPD-LSIA explained a higher share of variance and mediated the impact of MAS-A on MINI- ICF-APP. Levels of structural integration, including the quality of internalized object representations and unconscious interpersonal schemas, might therefore be considered as valuable predictors of social functioning and as one therapeutic focus in patients with non-affective psychoses. Structural integration might go beyond and form the base of a person’s actual reflexive and metacognitive capabilities. Psychotherapeutic procedures specific for psychoses may promote and challenge a patient’s metacognitive capacities, but should equally take the need for maturing structural skills into account. Modern psychodynamic approaches to psychosis are shortly presented, providing concepts and techniques for the implicit regulation of interpersonal experience and aiming at structural integration in this patient group.
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Theorists have suggested that individuals experiencing psychosis have significant affective dysregulation, and that expressions of psychosis may in fact serve as one form of expression of painful affect. As such, therapeutic approaches to work with individuals experiencing psychosis may incorporate therapist actions targeted to promote affect regulation in clients. Metacognitive Reflection and Insight Therapy (MERIT) is an integrative approach to psychotherapy that incorporates eight elements to target metacognition among individuals experiencing psychosis. MERIT has been shown to promote improvement in metacognition for persons with psychosis, but little has been done within this framework to explore the therapists’ role in promoting affect regulation among individuals experiencing psychosis. This paper discusses how therapist actions related to each of the eight components of MERIT may promote affect regulation in the therapeutic context. Case examples are given to illustrate the application of this approach. Common challenges faced among therapists, limitations, and future directions are also discussed.
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Research demonstrates ongoing health inequities for those from the most marginalized communities. To address these health inequities, medical educators have attempted to incorporate education that targets cultural competence of providers. Over the last decade, increasing evidence has demonstrated limitations to a competency-based approach. In this paper, we outline how utilizing critical reflection strategies in clinical supervision can be a long-term, sustainable approach for addressing health inequities, while improving the existing cultural competency model. We begin by demonstrating how existing ideas of critical reflection can be adopted to enhance learning within supervision by encouraging providers to evaluate and re-evaluate existing beliefs and biases. We then propose how an existing approach to treatment (i.e., Metacognitive Reflection and Insight Therapy) may serve as an example for how to activate critical reflection in supervision using three essential factors. Finally, we propose three clinical implications for providers that may work to dismantle existing healthcare inequities including: an increased comfort in feedback seeking, improved confidence working with diverse populations, and increased insight into how inequities emerge in clinical practice and how best to respond when they do.
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Supervision with international supervisees is both cross-cultural and cross-linguistic in nature. This study explored international supervisees’ experiences during the clinical supervision process, with 10 international supervisees (5 females, 5 males; Mage=31.60) participating in a qualitative study. Four themes were identified: (1) challenging aspects of being an international supervisee in supervision, (2) the supervisor’s multicultural competency or lack thereof, (3) growth-facilitating supervision strategies, and (4) addressing the supervision power differential. Findings provide a broadened vision of supervision with international trainees, helping mental health professionals better understand the unique challenges of supervision process with international trainees from a cross-cultural perspective.
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 recapturing a sense of self. To date, it is unclear how exactly the therapist establishes and then maintains an intersubjective connection in psychotherapy with persons with psychosis. In this article, we offer a three-step hierarchical model that describes observable therapist activities that promote intersubjectivity and facilitate the recovery process for individuals experiencing psychosis. We suggest the therapist activities needed to build mutual sense making include a foundational therapist openness to experience, which leads to the development of a dialectic of acceptance-challenge to fragmentation, and ultimately joint reflection that contributes to recovery of sense of self. The clinical implications and challenges of incorporating these types of interventions into clinical practice are discussed.
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Il est admis depuis quelques décennies que la schizophrénie est une pathologie mentale sévère de laquelle il est pourtant possible de se rétablir. Le rétablissement, notamment dans sa composante expérientielle, s’appuie sur les aspects subjectifs de l’expérience schizophrénique, bien étudiés par la littérature phénoménologique. Dans le cadre des soins orientés vers le rétablissement, Paul H. Lysaker a fondé un modèle de psychothérapie individuelle qui s’appuie sur l’approche métacognitive de la schizophrénie, concevant la pathologie mentale sévère comme une interruption du sens de soi. Il n’existe pas à ce jour de modèle théorique permettant de penser une psychothérapie collective visant le rétablissement expérientiel. Afin de répondre à cette lacune, notre travail se propose de tracer des voies d’accès conceptuelles, à partir d’outils théoriques empruntés à la psychopathologie phénoménologique et à l’approche métacognitive. Ces outils, articulés autour des concepts de centralité et de décentration, nous ont permis de penser la psychothérapie collective comme milieu métacognitif. ............................................................................................................................................................................................................................................................ It has been accepted for some decades that schizophrenia is a severe mental illness from which it is possible to recover. Recovery, particularly in its experiential component, is based on the subjective aspects of the schizophrenic experience, well studied by the phenomenological literature. In the context of recovery oriented care, Paul H. Lysaker founded a model of individual psychotherapy based on the metacognitive approach to schizophrenia, conceiving severe mental pathology as an interruption of the sense of self. To date, there is no theoretical model for thinking about collective psychotherapy aimed at experiential recovery. In order to respond to this gap, our work proposes to trace conceptual pathways, using theoretical tools borrowed from phenomenological psychopathology and the metacognitive approach. These tools, articulated around the concepts of centrality and decentration, have allowed us to think of collective psychotherapy as a metacognitive milieu.
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Metacognition refers to a spectrum of activities which spans from noticing discrete experiences to synthesizing them into a larger sense of the self and others. Evidence suggesting that deficits in metacognition are broadly present in schizophrenia and represent a potent barrier to recovery from schizophrenia has led to increasing interest in the development of metacognitively oriented treatments. In this article, we will describe the development of one such treatment, metacognitive reflection and insight therapy (MERIT), an integrative form of psychotherapy defined by eight core elements. We will first discuss the concept of metacognition as a means to operationalize the processes which enable persons to have a sense of themselves and others available for reflection and that can then serve as the basis for effective and agentic responses to psychosocial challenges. We will then discuss methods for assessing metacognition, the development of MERIT as a treatment that targets metacognition, and how MERIT compares with other treatments. Next, we will discuss empirical support for MERIT’s role in recovery including its potential to assist persons to develop their own personally meaningful sense of their challenges and then decide how to effectively respond to those challenges and manage their own recovery.
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The public stereotype of schizophrenia is characterized by craziness, a split personality, unpredictable and dangerous behaviour, and by the idea of a chronic brain disease. It is responsible for delays in help-seeking, encourages social distance and discrimination, and furthers self-stigmatization. This paper discusses the circumstances of the origins of the idea of a chronic brain disease (Emil Kraepelin, 1856-1926), of the split personality concept derived from the term "schizophrenia" (Eugen Bleuler, 1857-1939), and the craziness idea reflected in the "first rank symptoms", which are all hallucinations and delusions (Kurt Schneider, 1887-1967). It shows how Emil Kraepelin's scientific search for homogenous groups of patients with a common aetiology, symptom pattern, and prognosis materialized in the definition of "dementia praecox" as a progressing brain disease; how Eugen Bleuler's life and professional circumstances facilitated an "empathic" approach to his patients and prompted him to put in the foreground incoherence of cognitive and affective functioning, and not the course of the disease; finally, how Kurt Schneider in his didactic attempt to teach general practitioners how to reliably diagnose schizophrenia, neglected what Emil Kraepelin and Eugen Bleuler had emphasized decades earlier and devised his own criteria, consisting exclusively of hallucinations and delusions. In a strange conglomerate, the modern operational diagnostic criteria reflect all three approaches, by claiming to be Neo-Kraepelinean in terms of defining a categorical disease entity with a suggestion of chronicity, by keeping Bleuler's ambiguous term schizophrenia, and by relying heavily on Kurt Schneider's hallucinations and delusions. While interrater reliability may have improved with operational diagnostic criteria, the definition of schizophrenia is still arbitrary and has no empirical validity-but induces stigma.
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Research indicates that individuals with schizophrenia recover. Recovery, however means different things to different individuals and regardless of what kind of experiences define recovery, the individual diagnosed with the serious mental illness must feel ownership of their recovery. This raises the issue of how mental health services should systematically promote recovery. This paper explores the practical implications for research on metacognition in schizophrenia for this issue. First, we present the integrated model of metacognition, which defines metacognition as the spectrum of activities which allow individual to have available to themselves an integrated sense of self and others as they appraise and respond to the unique challenges they face. Second, we present research suggesting that many with schizophrenia experience deficits in metacognition and that those deficits compromise individuals’ abilities to manage their lives and mental health challenges. Third, we discuss a form of psychotherapy inspired by this research, Metacognitive Reflection and Insight Therapy which assists individuals to recapture the ability to form integrated ideas about themselves and others and so direct their own recovery. The need for recovery oriented interventions to focus on process and on patient’s purposes, assess metacognition and consider the intersubjective contexts in which this occurres is discussed.
Objectives Extensive research showed that one of the major difficulties that people with schizophrenia spectrum disorders are struggling with involves their ability to reflect on their own and others’ mental activities, also defined as metacognition. Several new psychotherapies have been developed to assist patients (re)gain metacognitive capacity, including Metacognitive Reflection and Insight Therapy (MERIT). The current study investigated the client's subjective experience of psychotherapy, to determine whether service users found MERIT effective and whether these gains align with quantitative findings, which processes they considered responsible for these benefits, in which ways participants found MERIT similar or different from other interventions, and whether they experienced non‐desirable factors and outcomes. Design All participants who had participated in a randomized controlled trial investigating the efficacy of MERIT were offered a structured post‐therapy interview by an independent assessor. Fourteen out of 18 (77%) participants, all of whom had completed therapy, responded. Results Most participants (10/14) indicated that they had experienced the therapy as beneficial to their recovery, and in general contributed to their understanding of their own thinking, which maps closely onto the quantitative findings reported elsewhere. They mainly attributed these changes to their own active role in therapy, the intervention letting them vent and self‐express, and forming an alliance with the therapist. Conclusions Participants reports of change map closely onto the quantitative findings from the randomized controlled trial. Findings are discussed in the frameworks of the metacognitive model of psychosis and the integrative intersubjective model of psychotherapy for psychosis emphasizing the role of the clients as active agent of change. Practitioner points • The use of a systematic, qualitative interview at the conclusion of therapy may yield important information regarding process and outcome. • Analysis of the interview revealed that clients’ perceptions regarding change within themselves closely maps onto quantitative findings. • MERIT may not be the appropriate intervention for all clients; some may prefer a more solution‐oriented approach such as CBTp or Metacognition‐Oriented Social Skills training. • Self‐expressing with a trained clinician may be therapeutic in itself.
Background/aims: Disturbances in first person experience is a broadly noted feature of schizophrenia, which cannot be reduced to the expression of psychopathology. Yet, though categorically linked with profound suffering, these disturbances are often ignored by most contemporary treatment models. Methods: In this paper, we present a model, which suggests that deficits in metacognition and their later resolution parsimoniously explain the development of self-disturbance and clarify how persons can later recover. We define "metacognition" as processes integral to the availability of a sense of self and others within the flow of life and report research suggesting its contribution to schizophrenia and link to self-disturbance. Results: We describe a newly emerging integrative form of psychotherapy, Metacognitive Reflection and Insight Therapy (MERIT), designed to target metacognition and enhance the recovery of healthy self-experience. We describe eight measurable core elements that allow MERIT to be operationalized and discuss about how to address disturbances in self-experience. Conclusions: We detail research that provides evidence of the feasibility, acceptability, and effectiveness of MERIT across a broad range of patients, including those who might not otherwise be offered psychotherapy. MERIT represents one form of psychotherapy that may address self-disorders among adults with schizophrenia.
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.
Background: First person, or subjective, experiences of persons with schizophrenia are recognized to play a fundamental role in the outcome. From psychoanalytic, existential, phenomenological, rehabilitation-oriented and dialogical perspectives, this review explores five descriptions of alterations in subjective experience, which are sometimes called self-disorders. While each provides rich accounts of these experiences, we conclude that each fails in some way to adequately account for how persons move into, or develop, alterations in self-experience, and how they move out of them or recover. Method: To address these limitations, we review research on the integrated model of metacognition in schizophrenia which offers an account of how self-experience may be compromised and later recaptured in ways that could be influenced by a range of psychological, social and biological phenomena. Results: We argue that research on metacognition suggests decrements in metacognitive function may partially account for the emergence of these difficulties and also explain how their resolution contributes to recovery. Conclusion: With the loss or recapture of metacognitive capacities, the socially-positioned, interpersonal lives of persons seem to lose or gain saliency, which in turn undermines or enables persons to develop a working sense of themselves that orients them purposefully and allows them to address challenges. Metacognitively oriented treatments which promote awareness of personal experience regardless of the level of fragmentation and work with persons as they slowly develop the ability to integrate information about themselves and others may offer unique promise for promoting recovery.
Background Impaired metacognition is associated with difficulties in the daily functioning of people with psychosis. Metacognition can be divided into four domains: Self-Reflection, Understanding the Other's Mind, Decentration, and Mastery. This study investigated whether Metacognitive Reflection and Insight Therapy (MERIT) can be used to improve metacognition. Methods This study is a randomized controlled trial. Patients in the active condition ( n = 35) received forty MERIT sessions, the control group ( n = 35) received treatment as usual. Multilevel intention-to-treat and completers analyses were performed for metacognition and secondary outcomes (psychotic symptomatology, cognitive insight, Theory of Mind, empathy, depression, self-stigma, quality of life, social functioning, and work readiness). Results Eighteen out of 35 participants finished treatment, half the drop-out stemmed from therapist attrition ( N = 5) or before the first session ( N = 4). Intention-to-treat analysis demonstrated that in both groups metacognition improved between pre- and post-measurements, with no significant differences between the groups. Patients who received MERIT continued to improve, while the control group returned to baseline, leading to significant differences at follow-up. Completers analysis (18/35) showed improvements on the Metacognition Assessment Scale (MAS-A) scales Self Reflectivity and metacognitive Mastery at follow-up. No effects were found on secondary outcomes. Conclusions On average, participants in the MERIT group were, based on MAS-A scores, at follow-up more likely to recognize their thoughts as changeable rather than as facts. MERIT might be useful for patients whose self-reflection is too limited to benefit from other therapies. Given how no changes were found in secondary measures, further research is needed. Limitations and suggestions for future research are discussed.
Poor insight impedes treatment in early phase psychosis (EPP). This manuscript outlines preliminary findings of an investigation of the novel metacognitively oriented integrative psychotherapy, Metacognitive Reflection and Insight Therapy, for individuals with early phase psychosis (MERIT-EP). Twenty adults with EPP and poor insight were randomized to either six months of MERIT-EP or treatment as usual (TAU). Therapists were trained and therapy was successfully delivered under routine, outpatient conditions. Insight, assessed before and after treatment, revealed significant improvement for the MERIT-EP, but not TAU, group. These results suggest MERIT-EP is feasible to deliver, accepted by patients, and leads to clinically significant improvements in insight.