Article

Restoring Trust for People With Psychosis Through Psychotherapy

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  • Eskenazi Health
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Abstract

Mistrust is a significant problem for people with psychosis and can interfere with their capacity to engage in psychosocial treatment. In this article, the developmental trajectory of mistrust is outlined, including the impact that attachment disruption, childhood trauma, attributional biases, internalized stigma, and discrimination can have on the person's capacity to form trusting bonds with others. After this review, three elements are described that may allow for the restoration of trust: the therapist's openness to understanding the patient's experience and agenda for therapy, the therapist's effort to honestly disclose their thoughts to encourage dialogue and mutual reflection, and therapist's attempt to promote metacognition through helping the patient develop more complex representations of the minds of others. These elements are framed in the context of metacognitive reflection and insight therapy, an integrative therapy that is well suited to address mistrust through its explicit focus on metacognition and intersubjectivity.

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... Psychosis can lead therapists to feel unable to meet the challenges at hand and therefore there can be fears about encountering one's limitations and having one's inadequacies exposed to colleagues or supervisors (Buck et al., 2014;Laufer, 2010). There are numerous obstacles that can interfere with successful therapy, including patients who are withdrawn (Saayman, 2020) and mistrustful (Ridenour et al., 2024), which can disrupt the formation of a therapeutic alliance. Therapists often do not know how to respond to the patient's disorganized thoughts (Hamm and Firmin, 2016) or delusions (Ridenour and Garrett, 2023) and are sometimes hesitant to engage due to worries about colluding with the patient's psychosis (McCabe and Priebe, 2008) or becoming part of the paranoid delusions (Saayman, 2021). ...
... Therapists often do not know how to respond to the patient's disorganized thoughts (Hamm and Firmin, 2016) or delusions (Ridenour and Garrett, 2023) and are sometimes hesitant to engage due to worries about colluding with the patient's psychosis (McCabe and Priebe, 2008) or becoming part of the paranoid delusions (Saayman, 2021). Therapists can feel awkward when speaking with patients about their psychotic experiences (Knutsson et al., 2023), especially if the patient wants to persuade the therapist to agree with their interpretations of reality (Ridenour et al., 2024). In response, the therapist may struggle to know how to respectfully balance their own perspective while also taking seriously the patient's experience. ...
... Too much reassurance may heighten suspiciousness and may be driven more by the therapist's own anxiety rather than by the patient's needs. Successful efforts may be those that are welcoming but not excessively or insincerely warm, which could be experienced as dishonest or intrusive (Ridenour et al., 2024). ...
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Fear is a central aspect of the experience of psychosis and can take many forms: Fears of psychosis itself, fears of fragmentation, and fears of frightening symptoms such as denigrating voices or persecutory agents. In addition, many people with psychosis are fearful of social rejection due to social stigma. While fear has long been essential to the conceptualization of psychosis and the topic of recent empirical investigation, there has been limited guidance available for therapists who want to help people with psychosis understand and address their fear in psychotherapy. Within the therapeutic context, therapists often experience their own fears of working with psychosis, which may include the worries about harm, experiences of confusion and disorientation that emerge when witnessing psychosis, and the fears of encountering their own inadequacy in the face of clinical challenges. After outlining these common fears that both therapists and patients often experience, four key practice elements are outlined that can reduce fear, including accepting fear and uncertainty in the face of fragmentation, adopting a courageous and vulnerable therapeutic stance, building trust within the therapeutic relationship, and making meaning of fear to enhance emotion regulation. Psychotherapy can be a key intervention to help people with psychosis acknowledge their experiences and learn to make sense of their fear and fragmentation by building a trusting relationship.
... The authors describe three elements that may allow for the restoration of trust: the therapist's openness to understanding the patient's experience and agenda for therapy, the therapist's effort to honestly disclose their thoughts to encourage dialogue and mutual reflection, and the therapist's attempt to promote metacognition through helping the patient develop more complex representations of the minds of others. Significantly, these are all elements that are also present in MCT (Ridenour et al., 2024). ...
... This Schneider et al., 2016) show that the main mechanism of MCT is the modification of cognitive biases, the construction of an intersubjective space appears to be an important additional benefit associated with the group format. It seems essential to facilitate interaction and the sharing of experiences among participants in order to enhance the therapeutic efficacy of the intervention (Ridenour et al., 2024). ...
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Objective Metacognitive training (MCT) for psychosis is a psychological intervention that blends cognitive behavioural therapy and psychoeducation. Several published systematic reviews and meta‐analyses have provided robust evidence of its efficacy. However, patients' opinions regarding the intervention or their own perception of the changes achieved have been overlooked. This study synthesises the first‐person reports of people with schizophrenia who completed MCT at the Hospital Del Salvador de Valparaiso. Methods This study employed a qualitative methodology. Semi‐structured interviews were conducted with patients who completed MCT. The interviews were reliably transcribed, and a content analysis was performed. Results All the participants interviewed were positive about MCT, highlighting improvements in various aspects and emphasising factors that contributed to the changes achieved. Four main themes emerged from the analysis: Sowing the seeds of doubt ; Significant changes in MCT attendees ; Community formation; and What the MCT needs to improve . Conclusions The results provide an in‐depth report on MCT from the users' perspective and allow reflection on new outcomes to be studied in the future, with quantitative and qualitative methods.
... This finding aligns with the calls to establish an environment that understands the bereavement response and is empathetic, thereby increasing the bereaved individuals' confidence in social networks (Zhou et al. 2023). Efforts to improve bereaved individuals' trust and interpersonal closeness might be helpful, such as promoting general trust through cognitive-behavioural therapy (Ridenour et al. 2024;Swan et al. 2017), facilitating cognitive change (McCullough 2003), drawing on trust-focused relational treatment (Purvis et al. 2013), training in interpersonal effectiveness skills (Barrett, Tolle, and Salsman 2017), and implementing behavioural activation (Smith, Pincus, and Ricca 2023). ...
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Traumatic death is a risk factor for prolonged grief. Network analysis offers a perspective for understanding traumatic bereavement at a symptom interaction level. This study estimates regularized partial correlation grief networks for bereavement due to earthquake ( n = 818) and illness ( n = 237), using symptoms from the Inventory of Complicated Grief (ICG) as the nodes. Difficulty in accepting death and loneliness were highly central nodes in both networks. Trust difficulties and longing for the deceased exhibited high centrality in the earthquake‐bereaved sample but not in the illness‐bereaved sample. The earthquake bereavement network was characterized by high connectivity and a diversity of central symptoms. These results provide insights into understanding the severity of grief after a traumatic loss. Although promoting the integration of the reality of loss and alleviating loneliness is important, it might also be worth considering the role of post‐loss interpersonal trust and the distress associated with longing for the deceased for traumatic bereavement.
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Objectives Though often a feature of schizophrenia-spectrum disorders, persecutory ideation (PI) is also common in other psychiatric disorders as well as among individuals who are otherwise healthy. Emerging technologies allow for a more thorough understanding of the momentary phenomenological characteristics that determine whether PI leads to significant distress and dysfunction. This study aims to identify the momentary phenomenological features of PI associated with distress, dysfunction, and need for clinical care. Methods A total of 231 individuals with at least moderate PI from 43 US states participated in a study involving 30 days of data collection using a smartphone data collection system combining ecological momentary assessment and passive sensors, wherein they reported on occurrence of PI as well as related appraisals, responses, and cooccurring states. Most (N = 120, 51.9%) participants reported never having received treatment for their PI, while 50 participants had received inpatient treatment (21.6%), and 60 (26.4%) had received outpatient care only. Results Individuals with greater functional disability did not differ in PI frequency but were more likely at the moment to describe threats as important to them, to ruminate about those threats, to experience distress related to them, and to change their behavior in response. Groups based on treatment-seeking patterns largely did not differ in baseline measures or momentary phenomenology of PI as assessed by self-report or passive sensors. Conclusions Smartphone data collection allows for granular assessment of PI-related phenomena. Functional disability is associated with differences in appraisals of and responses to PI at the moment.
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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 therapist, patient, and intersubjective factors are identified that can inhibit personal growth and lead to stalled treatments. After reviewing these various roadblocks, four principles (e.g., an intersubjective orientation to realty, therapeutic openheartedness/vulnerability, "speaking the unspeakable", and recognizing the pain beyond the psychosis) are outlined that can embolden the therapist to take judicious risks while avoiding common pitfalls when working with persons experiencing psychosis. These principles also enable the therapist to maintain an empathic connection to the patient and appreciate the pain beyond the psychotic symptom. The clinical implications and challenges of embodying these principles and implementing these interventions are discussed.
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Despite a substantial literature demonstrating effectiveness of psychotherapy for people experiencing psychosis, and a small body of work advocating for increased availability of psychotherapy for individuals with intellectual disability (ID), the intersection of psychosis and ID has been almost entirely neglected in the professional literature. In this article, the authors posit that an integrative psychotherapy approach, Metacognitive Reflection and Insight Therapy (MERIT), may be a feasible and effective approach for promoting recovery for individuals experiencing both psychosis and ID. The authors review the conceptual considerations for MERIT’s use with individuals with ID, highlighting the value of offering a treatment that recognizes the possibilities and importance of shared meaning making. Following this the authors present a case illustration of MERIT with a man diagnosed with schizophrenia and ID.
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Background: The relationship between attachment and paranoia is now well established. There is good theoretical reason and evidence to indicate that attachment style affects cognitive, affective, and behavioural processes which, in turn, contribute to the maintenance of paranoia, but this research has not been integrated. We critically and systematically review research that examines relevant cognitive, affective, and behavioural processes, which may explain how attachment insecurity leads to paranoia and constitute key targets in psychotherapeutic interventions for people with psychosis. Method: We conducted three systematic searches across six databases (PsycINFO, CINAHL, Medline, Web of Science, Embase, and Google Scholar), from inception to September 2021, to investigate key cognitive, affective, and behavioural processes in the attachment-paranoia association. Results: We identified a total of 1930 papers and critically reviewed 16. The literature suggests that negative self- and other-beliefs, inability to defuse from unhelpful cognitions, and use of maladaptive emotion regulation strategies mediate the association between attachment insecurity and paranoia in people with psychosis/psychotic experience. Attachment-secure people with psychosis are more likely to seek help and engage with services than attachment-insecure people. Conclusions: Attachment styles impact help-seeking behaviours in people with psychosis and are likely to influence paranoia via self- and other-beliefs, cognition fusion, and emotion regulation - these candidate mechanisms may be targeted in psychological therapy to improve clinical outcomes for people with psychosis, characterized by paranoia. Practitioner points: Insecure attachment is likely to lead to paranoia via negative beliefs about self and others, cognitive fusion, and use of maladaptive emotion regulation strategies. These mechanisms can be targeted in psychotherapeutic interventions for psychosis, such as cognitive behaviour therapy, to improve clinical and recovery outcomes. People with psychosis who are attachment-secure are more likely to seek help and engage with services than those who are attachment-insecure (particularly avoidant). Attachment style can be assessed to predict service engagement and help-seeking behaviours in people with psychosis. Attachment styles are important predictors of key cognitive, affective, and behavioural processes in people with psychosis. These processes can be assessed and incorporated into individualised formulations, and then targeted in therapy to effect psychotherapeutic change.
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To improve understanding of emerging psychosis, researchers have identified potential precursory mechanisms that may momentarily precede psychotic-like experiences, including aberrant salience and anomalous self-experiences. Aberrant salience is the misattribution of significance to neutral stimuli and may be linked to atypical dopamine transmission. Anomalous self-experiences include changes in the experience of the self, which may alter top-down cognitive processes. The present study extends previous research on these phenomena by examining the momentary dynamics of aberrant salience, anomalous self-experiences, and psychotic-like experiences in daily life. Participants were 246 young adults who were prompted to complete 6 smartphone surveys daily for 7 days. Baseline measures of aberrant salience and anomalous self-experiences each predicted occurrence of the same phenomena in daily life, supporting the use of these measures to examine within-subject changes. Dynamic structural equation modeling was used to examine lagged effects. Both aberrant salience and anomalous self-experiences exhibited carryover effects across timepoints. Furthermore, aberrant salience and anomalous self-experiences were each associated with psychotic-like experiences at subsequent timepoints, above and beyond the carryover effects of psychotic-like experiences. These temporal relationships provide preliminary support consistent with social-cognitive models of psychosis and support further examination of the within-subject dynamics of aberrant salience and anomalous self-experiences at the momentary scale. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Fomento de intersubjetividad en psicoterapia de psicosis: Aceptar y desafiar la fragmentación Las perspectivas históricas y contemporáneas han argumentado que las alteraciones en la experiencia del yo en la psicosis pueden revertirse con la ayuda de la psicoterapia. Se sabe menos acerca de las fuerzas particulares que estimulan tal cambio, aunque se ha argumentado que la intersubjetividad en la díada de la terapia contribuye a la creación de significados compartidos que permite el movimiento hacia la recaptura del sentido del yo. Hasta hoy en dia, no está claro cómo exactamente el terapeuta establece y luego mantiene una conexión intersubjetiva en psicoterapia con personas con psicosis. En este artículo, ofrecemos un modelo jerárquico de tres pasos que describe las actividades observables del terapeuta que promueven la intersubjetividad y facilitan el proceso de recuperación para las personas que experiencian psicosis. Sugerimos que las actividades del terapeuta necesarias para construir sentido mutuo incluyen una apertura fundamental del terapeuta a la experiencia, que conduce al desarrollo de una dialéctica de aceptación-desafío a la fragmentación y, en última instancia, a la reflexión conjunta que contribuye a la recuperación del sentido del yo. Se discuten las implicaciones clínicas y los desafíos de incorporar estos tipos de intervenciones en la práctica clínica.
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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 persons make sense of their experience of themselves and others. To explore the question of whether metacognitive research in psychosis offers unique insight in the midst of these other two emerging fields, we have offered a review of the constructs and research from each field. Following that summary, we discuss ways in which research on metacognition may be distinguished from research on social cognition and mentalizing in three broad categories: (1) experimental procedures, (2) theoretical advances, and (3) clinical applications or indicated interventions. In terms of its research methods, we will describe how metacognition makes a unique contribution to understanding disturbances in how persons make sense of and interpret their own experiences within the flow of life. We will next discuss how metacognitive research in psychosis uniquely describes an architecture which when compromised – as often occurs in psychosis – results in the loss of persons’ sense of purpose, possibilities, place in the world and cohesiveness of self. Turning to clinical issues, we explore how metacognitive research offers an operational model of the architecture which if repaired or restored should promote the recovery of a coherent sense of self and others in psychosis. Finally, we discuss the concrete implications of this for recovery-oriented treatment for psychosis as well as the need for further research on the commonalities of these approaches.
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Objectives Cognitive Behavioural Therapy for Psychosis (CBTp) demonstrates variable and at times mild to moderate effect sizes, thus its therapeutic processes are important to explore. Establishing a secure therapeutic relationship is one such key process where barriers may exist, including those related to psychotic symptoms and associated stigma. This review synthesizes the available qualitative research pertaining to the experience of the therapeutic relationship from the perspective of those experiencing psychosis. Methods A systematic review was under‐taken using PRISMA guidelines. Search terms included variants of ‘psychosis’, ‘therapy’ and ‘qualitative’. PsycInfo, CINAHL, EmBase, MedLine and Web of Science were searched and reference lists were hand‐scanned. Yardley’s quality appraisal tool was utilized and Noblit and Hare’s 7‐stage process for conducting a meta‐ethnographic review. A line‐of‐argument synthesis is presented. Results Fourteen papers were identified using inclusion and exclusion criteria. Twelve papers were deemed to have satisfactory quality. The line‐of‐argument synthesis used attachment theory to propose four semi‐distinct stages to establishing a therapeutic relationship; beginning; safety, hope and trust; the practicalities of therapy; branching out. Findings suggest that the therapist’s persona and use of CBTp techniques such as collaboration and shared agency over the process were important in establishing for the patient a sense of self as normal, equal and worthwhile. Conclusions Attachment security may be an important strand of CBTp and warrants further research and clinical investigation as a process and an outcome. Future research can benefit from increased transparency regarding researcher positionality as a potential source of bias.
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Background: Employment holds many benefits for people living with psychosis. However, significant barriers to employment for this cohort appear to exist, notably stigma and discrimination against people living with serious mental health conditions. We asked: Would a qualitative sample including multiple stakeholder groups reveal similar results and if so, what would be the main impacts of such stigma and discrimination? Method: This analysis used data from a qualitative study that had employed focus groups and interviews to investigate the employment barriers and support needs of people living with psychosis, including views of the multiple stakeholders (those living with mental health conditions, health professionals, care-givers, employments consultants and community members and employers). Results: The impacts of workplace stigma and discrimination on people living with psychosis included work avoidance, reluctance to disclose mental health conditions to employers, work-related stress, and reduced longevity of employment. Conclusions: Significant impacts from such stigma and discrimination were found in this study. The findings indicate a need to provide support mechanisms and to change the culture of workplaces to improve employment opportunities and outcomes for people living with psychosis.
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Objective: Preliminary evidence has found metacognitive capacity is associated with therapeutic alliance and with other outcomes in psychotherapy among persons with schizophrenia. The current study explored: (a) before to after changes in clients' metacognition capacity following Metacognitive Reflection and Insight Therapy (MERIT) and (b) whether the use of specific therapeutic elements of MERIT were followed by higher ratings of therapeutic alliance at the end of each session as well as with short-term outcome as measured prior to the next session, in a session-by-session intensive data collection. Method: Two hundred twenty-one sessions of 10 completers with schizophrenia who took part in an ongoing MERIT trial were analyzed. Measures of therapeutic alliance (short version of the Working Alliance Inventory), general outcome (Outcome Rating Scale), and metacognition (Metacognition Assessment Scale-Abbreviated) were used. Results: Findings showed significant change in 2 domains of metacognition, self-reflectivity and mastery, following therapy. In addition, the presence of 2 specific MERIT elements, the introduction of the therapist's mind and reflecting on the progress in therapy within a given session, were related to better outcomes in the following week. Finally, reflecting on the progress was also followed by higher therapeutic alliance. Conclusions: Metacognitively oriented therapy may positively affect both therapeutic alliance and short-term outcome. Specifically discussing the therapist's and client's experiences of what is occurring in therapy may positively affect short-term outcome and could be applicable to other psychotherapy approaches. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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As research on metacognition has progressed a significant array of definitions, methodologies and therapeutic applications have emerged. Some of this work has primarily framed metacognition as an activity carried out by one person in order to know, monitor, and adjust their beliefs, memories, and behaviors. Accordingly, problems with metacognition have often been characterized as issues related to cognition. This, however, risks neglecting how metacognition is also a fundamentally intersubjective act, one in which human beings know and reflect upon themselves and others primarily with and through connections with other people. In this paper, we review research on metacognition in schizophrenia using the integrative model of metacognition and a research paradigm in which metacognition is assessed within personal narratives. Stimulated by this work, we discuss how disturbances in intersubjective experience and metacognitive capacity mutually influence one another, with disruptions in metacognition perhaps more deeply understood as disruptions in relatedness with others. We then discuss how metacognition and intersubjectivity each affect mental health. We finally focus on the implications of this for treatments that target metacognition as well as future directions for research.
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Peter Fonagy is Head of the Division of Psychology and Language Sciences at University College London. He has occupied a number of key national leadership positions including Chair of the Outcomes Measurement Reference Group at the Department of Health, and Chair of two National Institute for Health and Care Excellence Guideline Development Groups. His clinical interests center on issues of early attachment relationships, social cognition, borderline personality disorder and violence, and today he will be speaking about epistemic petrification. He was interviewed at the Epistemic Petrification Conference, held on the 2nd-3rd July 2018, at Bristol University. The event was part of the Life of Breath project, sponsored by the Wellcome Trust.
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Background: Despite the evidence of the importance of including service users’ views on psychotherapy after psychosis, there is a paucity of research investigating impact on full recovery. Objectives: To explore what fully recovered service users found to be the working ingredients of psychotherapy in the recovery process after psychosis. Materials and Methods: The study was designed as a phenomenological investigation with thematic analysis as the practical tool for analysis. Twenty fully recovered service users were interviewed. Results: Themes: (1) Help with the basics, (2) Having a companion when moving through chaotic turf, (3) Creating a common language, (4) Putting psychosis in brackets and cultivate all that is healthy, and (5) Building a bridge from the psychotic state to the outside world. Conclusion: Therapeutic approaches sensitive to stage specific functional challenges seemed crucial for counteracting social isolation and achieving full recovery. Findings indicate that psychotherapy focusing on early readjustment to everyday activities, to what are perceived as meaningful and recovery-oriented, seems to be what is preferred and called for by service users.
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Over the past couple of decades, researchers have investigated the relationship between psychosis and social cognitive deficits and how these deficits might be targets for psychosocial treatments. Two important constructs related to social cognition are metacognition and mentalization, which have been developed into distinct therapeutic models for individuals with psychosis. Though metacognition and mentalization are conceptually similar, this review aims to provide a clearer delineation of each term by reviewing the definition, how they have been operationalized, and the application to the treatment of individuals with psychosis. We examined key theoretical papers, case studies, and clinical trials on mentalization and metacognition. Metacognition and mentalization share much in common though subtle conceptual distinction reveal key differences theoretically that have therapeutic implications. While emerging from divergent intellectual traditions, mentalization and metacognition complement one another and more trials are needed to examine the technical differences between these therapeutic approaches and the possibilities for both theoretical and technical integration. Keywords: Psychosis, Schizophrenia, Psychotherapy, Metacognition, Mentalization
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In Part 1 of this paper, we discussed emerging evidence suggesting that a general psychopathology or ‘p’ factor underlying the various forms of psychopathology should be conceptualized in terms of the absence of resilience, that is, the absence of positive reappraisal mechanisms when faced with adversity. These impairments in the capacity for positive reappraisal seem to provide a comprehensive explanation for the association between the p factor and comorbidity, future caseness, and the ‘hard-to-reach’ character of many patients with severe personality pathology, most notably borderline personality disorder (BPD). In this, the second part of the paper, we trace the development of the absence of resilience to disruptions in the emergence of human social communication, based on recent evolutionary and developmental psychopathology accounts. We argue that BPD and related disorders may be reconceptualized as a form of social understanding in which epistemic hypervigilance, distrust or outright epistemic freezing is an adaptive consequence of the social learning environment. Negative appraisal mechanisms become overriding, particularly in situations of attachment stress. This constitutes a shift towards a more socially oriented perspective on personality psychopathology in which the absence of psychological resilience is seen as a learned response to the transmission of social knowledge. This shift in our views has also forced us to reconsider the role of attachment in BPD. The implications for prevention and intervention of this novel approach are discussed.
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One aspect of schizophrenia contributing to its complexity is the lack of insight individuals often have into their illness. While poor insight is prevalent throughout the course of the illness, more severe levels are associated with first-episode psychosis (FEP). Interventions addressing insight are necessary but current treatments have been shown to have limited effectiveness. Thus, a novel intervention, Metacognitive Reflection and Insight Therapy (MERIT), is being studied for its efficacy of improving insight in individuals with schizophrenia spectrum disorders. MERIT is an integrative metacognitive therapy consisting of eight elements to assist clients in improving their ability to form complex ideas about themselves and others and to use this knowledge to respond to psychological problems. The present study is a case illustration of the implementation of MERIT to improve insight in FEP. Clinical outcomes were assessed and results showed that the client improved in both metacognition and insight. With replication, these results suggest that integrative metacognitive psychotherapy may serve as an intervention that improves insight in FEP, which marks an important step toward improved interventions for individuals with psychosis.
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Paranoia is a common symptom of schizophrenia that may be related to how individuals process and respond to social stimuli. Previous investigations support a link between increased paranoia and greater social cognitive impairments, but these studies have been limited to single domains of social cognition, and no studies have examined how paranoia may influence functional outcome. Data from 147 individuals with schizophrenia were used to examine whether actively paranoid and non-paranoid individuals with schizophrenia differ in social cognition and functional outcomes. On measures assessing social cognitive bias, paranoid individuals endorsed more hostile and blaming attributions and identified more faces as untrustworthy; however, paranoid and non-paranoid individuals did not differ on emotion recognition and theory of mind tasks assessing social cognitive ability. Likewise, paranoid individuals showed greater impairments in real-world interpersonal relationships and social acceptability as compared to non-paranoid patients, but these differences did not extend to performance based tasks assessing functional capacity and social competence. These findings isolate specific social cognitive disparities between paranoid and non-paranoid subgroups and suggest that paranoia may exacerbate the social dysfunction that is commonly experienced by individuals with schizophrenia.
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Background: Psychosis is associated with a high degree of stigma. There is relatively little qualitative research exploring service users’ experienced, perceived and internalised stigma and its impact on their lives.Material: Data from semi-structured interviews with 12 service users with experience of psychosis were subjected to secondary qualitative analysis.Discussion: Six overarching themes were identified concerning: understandings of psychosis; experiences of stigma; impacts on self; emotional responses; behavioural responses; and impact on recovery.Conclusions: Stigma is a key concern for service users with psychosis. Detailed assessment of stigma should be considered in clinical services and interventions developed to reduce stigma.
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Mentalizing-the capacity to understand others' and one's own behavior in terms of mental states-is a defining human social and psychological achievement. It involves a complex and demanding spectrum of capacities that are susceptible to different strengths, weakness, and failings; personality disorders are often associated with severe and consistent mentalizing difficulties (Fonagy & Bateman, 2008). In this article, we will argue for the role of mentalizing in the therapeutic relationship, suggesting that although mentalization-based treatment may be a specific and particular form of practice, the "mentalizing therapist" is a universal constituent of effective psychotherapeutic interventions. (PsycINFO Database Record (c) 2014 APA, all rights reserved).
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With the expectation that many can recover from schizophrenia, the implications for the roles of practitioners to assist them are critical. Although much has been written about how to empower a recovering person to develop a more positive identity, an important area which seems relatively underdeveloped in the literature pertains to the challenges and suffering borne from the process of recovery itself. The current paper will suggest that there are four related, though independent, challenges associated with the recovery process that practitioners should be prepared to address: (1) the discomfort elicited by the loss of, or threats to, a previous sense of identity, (2) the loss of previous ways of making meaning of the world, (3) awareness of concrete losses in one’s life which have occurred, and (4) accepting oneself as an ordinary, though agentic, person. For each we will review experimental, clinical, and first-person literature and refer to an illustrative vignette. Through recognition of these potentially painful challenges, practitioners may be even more effective in supporting recovery.
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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 empirical literature on grief associated with psychosis was conducted. Clinicians with significant therapeutic experience working with persons with psychosis reviewed cases to examine the losses the patients had suffered and how they responded to these losses. The clinicians considered essential principles that are relevant when helping patients with psychosis integrate loss and process grief. Results: Persons who have experienced psychosis often experience the loss of role functioning, interpersonal relationships, cognition, and self-concept. However, when these losses are not fully integrated into the person’s identity, it can result in either more losses due to denial and metacognitive impairments or increased hopelessness and depression due to internalized stigma. Five elements in psychotherapy of psychosis were identified that can facilitate the integration of loss and processing of grief: understand the personal experience of the psychotic episode, attend to feelings of grief and the primary loss, explore the meaning of psychotic symptoms and identity implications, integrate psychotic vulnerabilities into the sense of self, and foster realistic hope in the face of an uncertain future. Conclusion: Psychotherapy can enable persons with psychosis to make meaning of their losses, process their grief, integrate their psychotic vulnerability into their sense of self, and develop realistic hope.
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Research confirms that although patients experiencing psychosis want to speak about their symptoms with psychiatrists, psychiatrists are often hesitant to engage them directly in such conversations because of their fear of colluding, promoting defensiveness, or rupturing the therapeutic alliance. As a result, patients are often left to contend with confusing psychotic experiences, such as hallucinations and delusions, that they cannot make sense of on their own. In this article, the common barriers that prevent engagement in conversations about psychosis are described, and the conventional wisdom about the futility of talking with patients about delusions is challenged. The article suggests that instead of avoiding conversations about psychotic ideas, psychiatrists should embrace an “intent to understand,” an inquisitive state of mind even in the face of seemingly incomprehensible symptoms. Such a stance can promote the therapeutic alliance, deepen an understanding of the patient as a person, and facilitate an integrative recovery style. Finally, the article offers clinical pointers, including the importance of behaving courteously and respectfully, listening to the affect expressed in the symptom, and looking for connections between the symptom and painful life experiences. Maintaining an intent to understand may help psychiatric residents-in-training, as well as experienced clinicians, to foster an empathic understanding that builds a positive therapeutic alliance and contributes to more successful pharmacotherapy and psychotherapeutic interventions.
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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 explore this question, we investigated the association between clients' emotional experience and their session outcome evaluations and metacognitive growth in a metacognitively-oriented treatment, Metacognitive Reflection and Insight Therapy (MERIT). MERIT is a recovery-oriented treatment approach for psychosis that focuses on recapturing a coherent sense of self and personal agency by enhancing metacognitive capacity. Method Five-hundred-and-sixty-three sessions of 37 clients with schizophrenia who took part in an ongoing MERIT trial were analyzed. The Emotional Experience Self-Report (EE-SR) and Outcome Rating Scale (ORS) were collected on a session-by-session basis. Levels of metacognition ware assessed pre- and post-treatment using the Metacognitive Assessment Scale-Abbreviated (MAS-A) coding system. We used multilevel modeling to test our session-level predictions, and linear regression analysis for treatment-level predictions. Results Greater emotional experience, expression, and regulation within a session were associated with better session outcome. Regarding treatment level, greater emotional experience was associated with improvement in metacognitive mastery. Conclusions Our findings reveal that experiencing emotions in MERIT has significant implications for clients' subjective well-being during therapy sessions and for their ability to respond to psychological challenges using metacognitive knowledge. These findings lend weight to the idea that emotional experience is a key mechanism of change in metacognitive therapy for schizophrenia.
Article
Background Impaired trust in other humans is commonly seen in psychosis and it leads to poor societal functioning. However, examining trust behavior in an experimental setting is challenging. Investigators have used the trust game, a neuro-economic game to assess trust behavior in psychosis. However, the findings are inconsistent. Hence, we systematically reviewed the existing literature and conducted a meta-analysis to examine trust behavior in patients with psychosis, their relatives, and those at high risk for psychosis. Methods We searched electronic databases for studies that have examined trust game in patients with psychosis, published up to November 2021. The primary outcome measure was the baseline trust in a trust game by patients and controls. The meta-analysis was performed if at least three data sets of control and patient groups were available for that measure/design. We conducted meta-analyses with a random-effects model. The results were described narratively wherever meta-analysis was not possible due to paucity of studies. Results The searches across the databases including cross-references yielded 465 publications of which 10 studies were included in the final analysis. Baseline trust in the trust game was significantly lower in patients with psychosis compared to controls (SMD 0.39, 95% CI −0.14 to 0.64, p −0.002). However, a similar decrease in baseline trust was not present in relatives of patients (SMD 0.08, 95% CI −0.20 to 0.36, p −0.58). Conclusions The current meta-analysis suggests significant trust deficits in patients with psychosis. Future studies with a bigger sample size are required to understand the nature of trust deficits and factors affecting this impairment.
Article
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 experience. Specifically, we explore how metacognitive deficits may restrict awareness of {a} one’s and others’ purposes, {b} one’s sense of place in the world, and {c} the meaning of one’s actions. In turn, these restrictions compromise the evolution of narratives in response to experience, ultimately limiting access to features commonly associated with the good life.
Article
Background : The consequences of schizophrenia stigma are numerous and highly damaging to individuals, their families, the health care system and society. Mental health professionals (MHP) are considered to be one of the main sources of stigmatization. Objectives : To identify the characteristics of MHP stigma in schizophrenia in comparison with other psychiatric disorders, the specificities of MHP compared with other social groups, and associated factors. Methods : Following PRISMA guidelines, we systematically searched multiple electronic databases for articles: (i) reporting original data published in English in peer-reviewed journals, (ii) reporting quantitative data with statistical analysis, (iii) assessing stigma in a broad sense, and (iv) including samples composed only of MHP. Results : A total of 38 articles published from 1999 to 2019 and involving 10926 MHP fulfilled our inclusion criteria. Studies showed that schizophrenia is the most stigmatized mental illnesses in MHP, despite recent results suggesting that borderline personality disorder and substance abuse may be more stigmatized. In comparison with other social groups, MHP reported less dangerousness beliefs and more positive beliefs regarding pharmacological treatment. Nevertheless, results were less consistent regarding prognosis and desire for social distance. Age, education level, type of mental health profession, or length of practice were associated factors that showed inconsistent relations with stigma. Work setting and biological causal beliefs were more clearly associated with MHP stigma. Conclusion : These findings provide strong support for the need to conduct specific research on schizophrenia stigma in MHP and the importance of controlling for several variables to identify predictors of stigma.
Article
Background: Social cognition is often aberrant or impaired in psychotic disorders and related to functional outcomes. In particular, one core social cognitive bias – hostile attribution bias – is proposed to be implicated in paranoia, anxiety, mood disturbances and interpersonal conflict outcomes. However, questions remain about this domain’s specificity to psychosis and its relationship to general functional outcomes. Aims: The present paper offers a descriptive and critical review of the literature on hostile attribution bias in psychotic disorders, in order to examine (1) its impact on persecutory symptoms in schizophrenia-spectrum disorders, (2) impact on other related psychopathology among those experiencing psychosis and (3) relationship to functioning. Methods: Twenty-eight studies included in this review after parallel literature searches of PsycINFO and PubMed. Results: Evidence from these studies highlighted that hostile attribution bias is elevated in schizophrenia, and that it is related to anxiety, depression and interpersonal conflict outcomes. Conclusion: While results suggest that hostile attributions are elevated in schizophrenia and associated with symptoms and functioning, there exist numerous persisting questions in the study of this area, including identifying which measures are most effective and determining how it presents: as a state or trait-like characteristic, via dual processes, and its situational variation.
Article
Most existing measures of persecutory ideation (PI) rely on infrequent in-person visits, and this limits their ability to assess rapid changes or real-world functioning. Mobile health (mHealth) technology may address these limitations. Little is known about passively sensed behavioral indicators associated with PI. In the current study, sixty-two participants with schizophrenia spectrum disorders completed momentary assessments of PI on a smartphone that also passively collected behavioral data for one year. Results suggested that PI was prevalent (n = 50, 82% of sample) but had infrequent incidence (25.2% of EMA responses). PI was also associated with changes in several passively sensed variables, including decreases in distance traveled (Mkilometers = -1.20, SD = 18.88), time spent in a vehicle (Mminutes = -4.15, SD = 49.59), length of outgoing phone calls (Mminutes = -0.79, SD = 13.13), time spent proximal to human speech (Mminutes = -6.26, SD = 153.03), and an increase in time sitting still (Mminutes = 4.04, SD = 94.69). The present study suggests changes associated with PI may be detectable by passive sensors, including reductions in moving or traveling, and time spent around others or in self-initiated phone conversations. These constructs might constitute risk for PI.
Article
Objective: Determine whether metacognitive capacity (i.e., a range of abilities that involve recognition, reflection, and integration of mental states) influences the relationships between emotional distress and persecutory ideation (PI). Methods: The present study examined emotional distress, metacognition and PI in a sample (n = 337) of individuals with schizophrenia or schizoaffective disorder and clinician-rated PI. Pearson and partial correlations were used to examine relationships between variables, as well as between-subjects analysis of variances to compare groups characterized based on emotional distress and persecutory ideation scores. Results: While emotional distress and PI are associated with one another, metacognition is negatively associated with PI and positively associated with emotional distress. Subgroup comparisons demonstrated that individuals with high emotional distress and low PI had significantly higher metacognitive capacity than those elevated in PI or reduced in both emotional distress and PI. Conclusions: Findings suggest metacognitive capacity may relate to improved awareness of distress and reduced PI.
Article
Objectives: Schizophrenia is characterized by impaired social interactions and altered trust. In the general population, trust is often based on facial appearance, with limited validity but enormous social consequences. The aim was to examine trust processing in schizophrenia and specifically to examine how people with schizophrenia use facial appearance as well as actual partner fairness to guide trusting decisions. Design: An experimental economic game study. Methods: Here, we tested how patients with schizophrenia and control participants (each N = 24) use facial trustworthiness appearance and partner fairness behaviour to guide decisions in a multi-round Trust Game. In the Trust Game, participants lent money to 'partners' whose facial appearance was either untrustworthy or trustworthy, and who either played fairly or unfairly. Clinical symptoms were measured as well as explicit trustworthiness impressions. Results: Overall, the patients with schizophrenia showed unimpaired explicit facial trustworthiness impressions and unimpaired facial appearance biases in the Trust Game. Crucially, patients and controls significantly differed so that the patients with schizophrenia did not learn to discriminate in the Trust Game based on actual partner fairness, unlike control participants. Conclusion: A failure to discriminate trust has important implications for everyday functioning in schizophrenia, as forming accurate trustworthiness beliefs is an essential social skill. Critically, without relying on more valid trust cues, people with schizophrenia may be especially susceptible to the misleading effect of appearance when making trusting decisions. Practitioner points: Findings People with schizophrenia made very similar facial trustworthiness impressions to healthy controls and also used facial appearance to guide trust decisions similarly to controls. However, the patient group were less able to explicitly distinguish between fair and unfair partners based on their behaviour compared with the control group. Moreover, people with schizophrenia failed to use actual partner fairness to guide their financial decisions in the Trust Game, unlike controls, and this impairment was specific to a social task. People with schizophrenia may be particularly reliant on facial appearance when trusting others, as they may struggle to incorporate more valid trustworthiness information in their decision-making, such as actual partner fairness.
Article
This paper seeks to elucidate the phenomenological experience of psychotherapy in the context of the theory of mentalizing and epistemic trust. We describe two related phenomenological experiences that are the domain of psychotherapeutic work. The first is the patient’s direct experience of their own personal narrative being recognized, marked and reflected back to them by the therapist. Secondly, this intersubjective recognition makes possible the regulation and alignment of the patient’s imaginative capacity in relation to phenomenological experiences. In describing three aspects of the communication process that unfold in effective psychotherapeutic interventions – (1) the epistemic match, (2) improving mentalizing and (3) the re-emergence of social learning – the way in which any effective treatment is embedded in metacognitive processes about the self in relation to perceptual social reality is explained. In particular, attention is drawn to wider social determinants of psychopathology. We discuss the possible mechanism for the relationship between the socioeconomic environment and psychopathology, and the implications of this for psychotherapeutic treatment.
Article
Background: The felt and emotional aspects of psychosis are poorly understood, however, their importance for the aetiology of, and recovery from, psychosis is increasingly accepted. Individuals experiencing psychosis often come into contact with mental health services during a crisis. Currently little is known about the emotional and felt aspects of this experience, yet this could support clinical intervention at this time. Aims: This research aims to gain an in-depth understanding of the lived, felt experiences of a first crisis in psychosis. Method: The study took a hermeneutic phenomenological perspective and utilised visual methods. Seven participants participated in idiographic, multi-modal interviews about their experiences. Results: Participants described their first crisis in psychosis as a shattering experience, entwined with their experiences of interpersonal trauma. In crisis, participants lost basic trust in the world; felt enveloped in a strange, threatening atmosphere, and lacked a sense of belonging. Conclusions: Attention to the felt aspects of a crisis indicate the existential, intersubjective and traumatic nature of the experience. Psychosocial, family and trauma-focused approaches that take into account the holistic, embodied and contextual nature of psychosis experiences seem best-placed to support treatment and research in this area.
Article
Despite long-standing pessimism, it is now widely recognized that individuals with psychosis can recover if offered meaningful psychotherapeutic treatments. This paper provides an overview of psychotherapeutic approaches and models for treatment for individuals who experience psychosis. We selected psychotherapeutic models from diverse theoretical orientations (e.g. cognitive-behavioral, acceptance and commitment therapy, psychodynamic, and integrative) to highlight different treatment philosophies and models for interventions. Although some of these therapies have yet to establish an empirically supported evidence base, they have been selected for review in light of their respective emerging literatures and because they offer distinct methods of understanding and treating severe ‘mental illness’. This review article provides clinicians with different approaches to treatment that will allow them to explore various interventions to provide integrative care for individuals experiencing psychosis. This paper indicates that evidence-based psychotherapies for psychosis are just emerging and that newer therapies should be considered to provide a range of treatment options. More research is needed to develop efficacious treatments that not only alleviate distress but also promote meaningful recovery for individuals with psychosis.
Article
A precarious balance exists between remaining faithful to one’s own language and history while also maintaining an ethical attentiveness to the Other. The danger in the former is the penchant for colonizing and violently reducing the Other. The danger of the later is a supine servility and inability to offer a linguistic home for welcoming the Other. To navigate these two extremes, the conditional hospitality of Ricoeur’s hermeneutics is brought into dialogue with the unconditional hospitality of Derrida’s deconstruction. What is needed is the more embodied approach of a carnal hospitality that assists in discerning the right ways of touching and not touching, of uniting word and body, teaching us how to incarnate the impossible possibility of reconciliation and forgiveness with the stranger.
Article
People with schizophrenia spectrum disorder face a major challenge in the ability to reflect on their own and others' mental activities and about specific psychological problems in their lives. These deficits are associated with increased symptoms and lower functioning. Specific interventions have been designed to enhance these abilities, one of which is metacognitive reflection and insight therapy (MERIT). Several case studies and a recent pilot study have shown increased metacognitive abilities and a decrease in symptoms among clients after MERIT. This article presents two case studies of clients diagnosed with schizoaffective disorder whose psychotherapy, conducted in Israel, incorporated the MERIT protocol. Outcome measures were taken before and after treatment, and metacognitive abilities were assessed at five time points throughout treatment. Clinical implications and limitations are discussed.
Article
People with schizophrenia spectrum disorder face a major challenge in the ability to reflect on their own and others' mental activities and about specific psychological problems in their lives. These deficits are associated with increased symptoms and lower functioning. Specific interventions have been designed to enhance these abilities, one of which is metacognitive reflection and insight therapy (MERIT). Several case studies and a recent pilot study have shown increased metacognitive abilities and a decrease in symptoms among clients after MERIT. This article presents two case studies of clients diagnosed with schizoaffective disorder whose psychotherapy, conducted in Israel, incorporated the MERIT protocol. Outcome measures were taken before and after treatment, and metacognitive abilities were assessed at five time points throughout treatment. Clinical implications and limitations are discussed.
Article
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.
Article
Psychotic disorders often have been linked with violence. However, studies have shown that people with a psychotic disorder are more often victim than perpetrator of violence. The objective of this meta-analysis was to review prevalence rates for different types of victimization and to identify risk factors associated with victimization. Based on a search in MEDLINE, PsycINFO, and Web of Science, 27 studies were found with samples consisting of adults with a psychotic disorder and possible victimization occurring during adulthood and data on "violent victimization," "sexual victimization," "non-violent victimization," and/or "victimization not otherwise specified." The median prevalence rate for violent victimization was 20%, for sexual victimization 20%, nonviolent victimization 19%, and for victimization not otherwise specified 19%. Victimization rates were approximately 4-6 times higher than in the general community. Meta-analyses showed the following significant risk factors: delusion (OR = 1.69), hallucinations (OR = 1.70), manic symptoms (OR = 1.66), drugs (OR = 1.90) or alcohol abuse (OR = 2.05), perpetration of a crime (OR = 4.33), unemployment (OR = 1.31), and homelessness (OR = 2.49). Other risk factors like previous victimization, impaired social functioning, personality disorder, and living in a disadvantaged neighborhood were found only in 1 or 2 studies. Based on the results, we conclude that, depending on the examined time period, 1 in 5 (assessment period ≤3 y) or 1 in 3 (assessment period entire adulthood) people with a psychotic disorder was victim of a crime. Clinical, behavioral, and sociodemographic factors were significantly associated with victimization, as well as previous victimization. Prospective research into risk factors is needed to capture causal trajectories of victimization.
Article
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.
Article
Loneliness may be related to psychotic symptoms but a comprehensive synthesis of the literature in this area is lacking. The primary aim of the current study is to provide a systematic review and meta-analysis of the association between loneliness and psychotic symptoms in people with psychosis. A search of electronic databases was conducted (PsychINFO, MEDLINE, EMBASE, and Web of Science). A random effects meta-analysis was used to compute a pooled estimate of the correlation between loneliness and psychotic symptoms. Study and outcome quality were assessed using adapted versions of the Agency for Healthcare Research and Quality (AHRQ) tool and GRADE approach, respectively. Thirteen studies were included, providing data from 15 647 participants. A moderate association between psychosis and loneliness was observed (k = 13, N = 15 647, r = .32, 95% CI 0.20, 0.44; I2 = 97.56%; moderate quality evidence). Whether loneliness was assessed by a single-item or a more comprehensive measure had no moderating effect on the estimate. Results indicate that there is a significant positive relationship between loneliness and psychosis. Further studies are needed to determine the causal status of this relationship, but this robust finding should be considered in clinical practice and treatment provision for those with psychotic disorders.
Article
A spectrum of severity of paranoia (unfounded thoughts that others are deliberately intending to cause harm) exists within the general population. This is unsurprising: deciding whether to trust or mistrust is a vital aspect of human cognition, but accurate judgment of others' intentions is challenging. The severest form of paranoia is persecutory delusions, when the ideas are held with strong conviction. This paper presents a distillation of a cognitive approach that is being translated into treatment for this major psychiatric problem. Persecutory delusions are viewed as threat beliefs, developed in the context of genetic and environmental risk, and maintained by several psychological processes including excessive worry, low self-confidence, intolerance of anxious affect and other internal anomalous experiences, reasoning biases, and the use of safety-seeking strategies. The clinical implication is that safety has to be relearned, by entering feared situations after reduction of the influence of the maintenance factors. An exciting area of development will be a clinical intervention science of how best to enhance learning of safety to counteract paranoia.
Article
Emerging integrative psychotherapy approaches for schizophrenia have received increased attention and support, but little has been published exploring concepts and challenges pertinent to the supervision and training of clinicians working within an integrative psychotherapy framework with persons with schizophrenia. In this article, one general concept related to intersubjectivity, referred to as the development of an open interpersonal psychotherapist stance, is explored within the context of supervision. General considerations for supervision are offered regarding the development of an open interpersonal stance, and strategies for addressing four prototypical non-open stances in which dialogue may be disrupted are delineated.
Article
Distrust and social dysfunction are characteristic in psychosis and may arise from attachment insecurity, which is elevated in the disorder. The relationship between trust and attachment in the early stages of psychosis is unknown, yet could help to understand interpersonal difficulties and disease progression. This study aimed to investigate whether trust is reduced in patients with early psychosis and whether this is accounted for by attachment avoidance and attachment anxiety. Method We used two trust games with a cooperative and unfair partner in a sample of 39 adolescents with early psychosis and 100 healthy controls. Results Patients had higher levels of attachment anxiety, but the groups did not differ in attachment avoidance. Basic trust was lower in patients than controls, as indicated by lower initial investments. During cooperation patients increased their trust towards levels of controls, i.e. they were able to learn and to override initial suspiciousness. Patients decreased their trust less than controls during unfair interactions. Anxious attachment was associated with higher basic trust and higher trust during unfair interactions and predicted trust independent of group status. Discussion Patients showed decreased basic trust but were able to learn from the trustworthy behaviour of their counterpart. Worries about the acceptance by others and low self-esteem are associated with psychosis and attachment anxiety and may explain behaviour that is focused on conciliation, rather than self-protection.
Article
When I received the invitation to talk to you about psychotherapy of schizophrenia, I gave a good deal of thought to the question of how you might like me to approach the topic. Finally, I felt it might be most ap-propriate to report the development in the understanding and the technique of our clinical work since ii 8 when I had the privilege to talk to you about it at the schizo-phrenia symposium during the annual meet-ing in Washington. The goal of psychotherapy with schizo-phrenics was seen then, as it is now, as helping them by a consistent dynamically oriented psychotherapeutic exchange to gain awareness of the unconscious motivations for and curative insight into the genetics and dynamics of their disorder. As a result of the continued research which is inherent in dynamic psychotherapy, I have gained some further insight into the dynamics of schizophrenic symptomatology from which have evolved some variations in the details of the treatment. Briefly, they are: i. The old hypothesis according to which the schizophrenic's early experiences of warp and rejection were of over-all significance for the interpretive understanding and treat-ment has been somewhat revised.