Out of Illness Experience: Metacognition-Oriented Therapy for Promoting Self-Awareness in Individuals with Psychosis

Introduction

Contrary to a long-standing pessimistic opinion, most people with schizophrenia move towards meaningfully recovery over the course of their lives (Bellack, 2006; Lysaker & Buck, 2008; Silverstein, Spaulding & Menditto, 2006). The improvement involves not only patients’ symptoms and social functioning, but also in the ability to think about themselves as agents in the world (Resnick, Rosenheck & Lehman, 2004; Roe, 2001; Silverstein & Bellack, 2008). The growing awareness that recovery is possible has raised interest in refining psychotherapy models aimed at promoting recovery and wellness. Perhaps the most prominent among these involve cognitive behavioral therapy (CBT; Wykes, Steel, Everitt & Tarrier, 2008). Cognitive behavioral therapy aims at alleviating distress arising from delusional beliefs and hallucinatory experiences through a systematic, collaborative process of normalizing unusual experiences, placing such experiences in their social, cultural and historical context, through shared case formulation and testing, and evaluating alternative behavioral strategies and beliefs about those experiences. Evidence from controlled trials shows that persons with schizophrenia are willing to receive CBT and that it can reduce distress arising from psychotic experiences (Drury, Birchwood, Cochrane & MacMillian, 1996; Sensky, Turkington, Kingdon et al., 2000; Gumley, O’Grady, McNay et al., 2003;Wykes et al., 2008; Lysaker, Davis, Bryson, & Bell, 2009). Despite these positive results, there is limited evidence from Wykes et al. (2008) that CBT reduces overall emotional dysfunction including anxiety or depression, reduces relapse and improves interpersonal and social functioning. In this context, attention has turned to whether psychotherapy might promote recovery by helping persons with schizophrenia develop self-acceptance and self-awareness (Chadwick, 2006) and a richer sense of personal identity as embedded in their unique personal histories or narratives (France & Uhlin, 2006; Lysaker, Buck, & Roe, 2007; Silverstein et al., 2006). Psychotherapy can represent a situation in which individuals develop richer and more layered stories about who they are in the present, who they have been during the course of their lives, and what their future might be (Adler, Skalina, & McAdams, 2008; Hermans & Dimaggio, 2004; Lysaker & Lysaker, 2006). A more thorough personal narrative might then naturally represent the opportunity to experience oneself as an active agent prevailing in the face of adversity which may lead to reductions in other aspects of the disorder such as symptoms (Lysaker, Davis, Jones et al., 2007; Lysaker, Carcione, Dimaggio et al., 2005; Harder, 2006; Lysaker, Buck, Hammoud, et al., 2006).

To promote changes in narrative and self schemata, some authors stress that if it is to be effective, psychotherapy for persons with schizophrenia should take into account difficulties many individuals experience in relation to the metacognitive system (Dimaggio & Lysaker, 2010; Semerari, Carcione, Dimaggio et al., 2003) or the abilities needed to understand mental states, both of oneself and of other people (Brüne, 2005; Langdon, Coltheart, & Ward, 2006; Lysaker, Dimaggio, Buck et al. 2007; McGlade, Behan, Hayden et al., 2008). Metacognitive problems in schizophrenia are believed to be relatively trait-like and correlated with deficits in neurocognition (Lysaker et al., 2005; 2007) as well as relational variables including trauma history (Lysaker, Gumley, Brüne, et al., in press). The impact of this deficit on functioning though is likely only to become evident when patients are faced with situations in which they have to swiftly and skillfully understand what they and the others think and feel (and why they do so), in order to solve social problems, to pursue goals as obstacles appear, and to negotiate meaning (Lysaker, Shea, Buck et al., 2010; Lysaker, Erickson, Buck et al., in press, available online). Because of these difficulties in understanding mental states, some patients enter a hypermentalizing mode (Abu-Akel, 1999; Brüne, 2005) in which they are bombarded with an overwhelming variety of ideas about what is occurring interpersonally, with no single idea appearing more likely than another to clarify the situation, leading to a tendency to disengage from others and withdraw (Salvatore, Dimaggio, & Lysaker, 2007).

One particularly significant metacognitive problem, which might be a focus of therapy, pertains to self-awareness. Many with schizophrenia have difficulties describing their emotions and thoughts and establishing psychologically valid cause-effect chains among events, thoughts, emotions, and actions. Mounting evidence suggests that impairment in this and related aspects of metacognition are linked with greater levels of social and vocational dysfunction in schizophrenia (Bora, Eryavuz, Kayahan, et al., 2006; Brüne, Abdel-Hamid, Lehmkämper, & Sonntag, 2007; Lysaker, Dimaggio, Carcione et al., 2010) and may mediate the impact of deficits in neurocognition on social adaptation (Bell, Tsang, Greig, & Bryson, in press; Lysaker, Erickson, Buck et al., in press, available online; Lysaker, Shea, Buck et al., 2010)

Regarding what might be involved in targeting self-reflectivity in psychotherapy preliminary evidence coming from single cases (Lysaker, Buck & Ringer, 2007; Buck & Lysaker, 2009; Lysaker, Buck, Carcione et al., 2011; Salvatore, Dimaggio, Popolo et al., 2009) advocate psychotherapy for schizophrenia be tailored to a client’s metacognitive abilities and that its evolution be tracked over time. This form of therapy recognizes that before many patients can use cognitive restructuring or other CBT techniques, thry may have to first develop a level of metacognitive abilities sufficient to question their own beliefs. Lysaker, Buck, Carcione and colleagues (2011; see also Buck & Lysaker, 2009) have suggested that applying CBT techniques is less stressful and more effective when a careful assessment of self-reflective skills has been made. Anecdotal evidence has recently blended with the development of metacognition-oriented procedures for treating people with personality disorders (Dimaggio, Salvatore, Nicolò et al., 2010) which are aimed at progressively promoting a coherent life-narrative and helping people acquire the capacity to successfully engage in the simplest elements of the metacognitive system (e.g. being aware one is angry), and then later to be able to perform the more complex elements (e.g. taking a critical distance from rigid schema-driven attributions to self and others).

Step-by-step procedures for addressing the metacognitive capacities of people with schizophrenia have thus been devised (Salvatore, Dimaggio, Popolo, 2010; Lysaker & Buck, 2010) using levels of self-reflective abilities as a guide. As defined by Lysaker et al. (2005) and Semerari et al. (2003), the therapist attempts to assess what level of cognitive complexity therapy should address first. Then, after noting progress, the next and more complex intervention can be made. We summarize here the first steps in the sequence, as these are the ones illustrated in the session excerpt that we analyze.

In this paper we implement these key steps in the therapy model and use it as a guide for a Metacognition-Oriented Therapy for Psychosis as introduced in a manual paper (Lysaker & Buck, 2010). In this manual paper the authors start from the perspective that many with schizophrenia vary in their capability to construct complex representations of themselves and others. On this basis they state that, in addition to symptom reduction and helping patients to succeed in specific social roles (e.g., work on family relationship), psychotherapy—after a therapeutic relationship has been created—can aid in the recovery of metacognitive capacities, by providing a place in which such capacities can be practiced and exercised in order of increasing complexity. In this approach the therapist in every session first ascertains the level of metacognition the client has achieved and then offers back observations or challenges about matters appropriate to that level. For example, if patients are struggling to recognize their thoughts as their own, a possible comment the therapist could make might be: “You can only think about being kidnapped today, and there is no room for other ideas or people”. If patients are struggling to their own distinct emotions, a possible challenge the therapist can make is: “You described a situation in which X and Y happened, but you did not mention how you felt”.

Going further than the manual paper, here we focus on eliciting the details of a narrative scenario in order to have a text on which to look for mental states (Dimaggio et al., 2010) and we highlight the importance of validating patients’ experiences as they emerge.

In particular, we intensively analyze excerpts of one tape-recorded and transcribed therapy session in which the therapist sequentially tried to: 1) reconstruct episodes in a life-narrative until a clear-enough scene had been set; 2) help the patient name distressing emotions that appear in the narrative episode; 3) validate and normalize the patient’s experience; 4) promote awareness of the triggering factors for any specific emotions; and 5) validate emerging subjective experience. We suggest that, like physical therapy, psychotherapy can offer clients the possibility over time of re-developing the capacity to engage in acts they were once able to perform (Lysaker & Buck, 2010).

Finally, a metacognitive-oriented psychotherapy operates in the context of a constant, tactful regulation of the therapy relationship and of an attention to preventing and repairing therapeutic alliance ruptures (Safran & Muran, 2000). Therapists should constantly try to validate subjective experience before pointing out any problematic aspects inherent in it (Kelly, 1955; Dimaggio, Semerari, Carcione et al., 2007; Linehan, 1993). They should strive to make patients feel there is always something shareable and worthy in their personal, albeit distressing, experiences.

Case Presentation

Roberta, 37 years old, began to experience positive symptoms of schizophrenia one year before being examined by one of us (GS). She was convinced that the man with whom she had a romantic relationship was a lost relative. She was convinced this relative had always loved her and had always hidden his kinship until now. Roberta and her partner broke up and she then began stalking him. He in turn sued her. Roberta also experienced delusions of reference—e.g. she thought some TV soap opera characters were talking about her life and love affairs—and disorganization of thought and speech. Her behavior at this point was exceedingly extroverted and bizarre, and she lacked minimal awareness of being unwell. Roberta also experienced auditory hallucinations consisting of hearing people commenting on her actions. She met criteria for disorganized schizophrenia (DSM-IV, APA, 2000). At the moment of the assessment, Roberta was severely socially withdrawn.

Until the consultation described here, Roberta had refused medication and had dropped out of two previous psychotherapies. Forced hospitalization was necessary to initiate appropriate medication, and she started psychotherapy soon after, while taking olanzapine, venlafaxine, and topiramate. Medications reduced psychomotor agitation, positive symptoms and thought disorganization, but she remained withdrawn and unable to engage in social exchanges. When a conversation started in an interpersonal transaction, she became anxious and confused about what was going on in the interaction and withdrew, thinking others had malevolent intentions towards her.

As her symptoms receded, Roberta also became more aware of how poor the quality of her life was and she was confused and felt unable to find any viable project to pursue. She wanted to work in a legal firm but she had lost any hope of achieving it. Reasonable goals were for her to spend more time with her daughter and help her with her homework.

History

Roberta came from a small town in Southern Italy and was an only child. She described her relationship with both parents as good overall, even though her mother’s strong personality had always prevented her from talking openly and confidentially. She had been timid and socially avoidant since childhood. Her adolescence was characterized by a marked dependence on caregivers, together with an avoidance of social relationships and a growing sensation that she was different from others and an outcast. She achieved a law degree but failed to become a lawyer because of anxiety she experienced before each examination. She had had only two significant romantic relationships, one leading to marriage. However, she soon experienced her husband as totally absorbed in his work and emotionally absent from the relationship. They lived with her husband’s parents, and Roberta was forced to spend a lot of time with them. She felt manipulated and considered that her choices and her role as a wife were not being respected. In this context Roberta started an extramarital relationship with a work colleague that lasted about ten years. After being strongly urged by her relatives, who pointed out that her marriage had failed, Roberta separated from her husband. She gained custody of her daughter, and she moved to her mother’s home after a few months. Shortly thereafter, Roberta’s relationship with the colleague ended, by decision of the latter. Soon afterwards, Roberta’s father died. About one month later, her psychotic symptoms first emerged.

Psychotherapy Technique and Process

Roberta had weekly psychotherapy for six months in a private outpatient clinic. At the client’s request, sessions lasted about 40 minutes. The client attended 100% of the scheduled weekly appointments. The psychotherapist (GS) was a psychiatrist with more than 10 years of experience working with persons with psychosis and personality disorders. The treatment focused on metacognitive dysfunctions, i.e. difficulties in understanding both one’s own and others’ mental states and in using psychological knowledge to master one’s confusion and anxiety in social situations. Once her capacity for metacognition had improved, the goal became to use her new knowledge of her own mental states to overcome social withdrawal. The therapy process is depicted with excerpts from a taperecorded session. The patient gave informed written consent to taperecord and transcribe the session and use selected excerpts for scientific purposes.

We selected this session because it illustrates all five therapy steps we focus on in this paper, i.e.: 1) reconstructing episodes in a life narrative until a clear-enough scene has been set; 2) helping the patient name the problematic emotions appearing in the episodes collected; here the therapist tries to suggest emotional labels for inchoate experiences until the patient’s feedback is positive, as evident from both verbal and non-verbal cues about a specific emotion having been actually experienced; 3) validating and normalizing the patient’s experience; 4) promoting awareness of the triggering factors for each specific emotion; and 5) validating the emerging subjective experience.

Step 1: Reconstructing Episodes in a Life Narrative

The most reliable texts for accessing elements of self-experience are autobiographical memories, which contain the essence of how patients construe their relationships with others on the basis of their motivations (Angus & McLeod, 2004). An adaptive narrative takes place within defined spatial (where) and time (when) boundaries. The actors (who), the subject they engage in dialogue about (what) (Hermans & Dimaggio, 2004) and the purpose for which the story is told (why) should be identifiable (Neimeyer, 2000; Dimaggio, Salvatore, Nicolò, et al. 2010).

In the following excerpt the therapist starts from a cue provided by Roberta. The therapist then seeks detail and following a set of focused questions, a specific episode appears:

In the section above, Roberta begins talking about a vague feeling of uneasiness connected to a series of interpersonal events but did not provide a specific episodic memory regarding it. The therapist asked her for specific episodes, explaining that the more detailed a story was, the easier it would be to achieve a mutual understanding of what was happening. This prepared the ground for the move to the next step. His questions allowed for Roberta to slowly become aware of a clear memory and the therapist used that shortly afterwards to probe for information about the states of mind that were nested in this episode.

Step 2: Helping the Patient Name Distressing Emotions that Appear in the Narrative Episode

In the second step the therapist focused on having Roberta understand the thoughts and feelings that she was experiencing during a precise moment in their narrative and then identify the causal links among and the logical and psychological implications of elements of experience. Here the therapist posed questions or proffered hypotheses about what kind of emotion might match each subjective experience or, once inner states are clear, what caused an emotion or triggered a reaction. If particular thoughts caused particular actions or affects, he explored the links between details in a narrative—what someone said or did—and a patient’s actions:

The patient initially described her inner states, but in vague terms (“… a bit uneasy … upset me a bit”), so that her emotions were unclear to both herself and the therapist. As suggested in the manual paper (Salvatore, Lysaker, Popolo et al., 2011), the therapist should now focus on helping the patient distinguish different emotions from one another or, if that is not possible, just to notice the different mental contents she is experiencing. Other interventions, for instance the challenging of the accuracy of specific beliefs that require higher-order metacognitive skills, are discouraged as the patient would probably not be able to make sense of them. The therapist now thinks with the patient about the emotions she is experiencing and focuses on nonverbal language, nuances or changes in tone of voice and posture to get Roberta to access her inner states.

In this segment the therapist tried suggesting emotional labels for the patient’s inchoate experiences until her feedback, in the shape of both verbal and nonverbal cues, showing that a specific emotion was actually experienced, was positive. This intervention was based on his assessment of her metacognitive capacity, that is, of the maximal level of complexity she could think about her own thinking. The therapist again avoided at this stage working to promote more metacognitively complex operations, such as emotional regulation which would require an understanding of inner states that the patient had barely developed. At the same time, though Roberta recounted distressing interpersonal exchanges, the therapist did not suggest coping strategies, or try to solve her problems by thinking for her. Such a strategy might have worked against her developing that capacity or overwhelmed the patient.

Step 3: Validating and Normalizing the Patient’s Experience

Validation consists, on one hand, of confirming the sense of the forecasts and evaluations that a person constructs: “I understand that you can have this point of view about the world” (Kelly, 1955), and on the other hand, is about the therapist stressing the comprehensible and acceptable nature of at least part of patient’s dysfunctional experience: “I understand how you can feel like that” (Linehan, 1993). To accomplish this most simply, the therapist needs to communicate that he understands the patient and can make sense of even the most painful emotions or bizarre experiences. In essence, we suggest that the therapist’s task is to offer the idea that the patient’s internal experiences are comprehensible in a way that creates an atmosphere of trust, in which the patient can metacognitively reflect on her experiences.

The next excerpt shows the therapist working to validate emotions’ under stressful conditions.

The therapist here has sought to create a sense of sharing and to promote a sense of sharedness (Dimaggio et al., 2007). A crucial aspect of validation is the creation of a sense that one’s experiences are normal, understandable, and connected to a wider world of experiences. The therapist here stressed that the patient’s experience made sense to him as something typically human (Safran & Muran, 2000). Such an intervention is both a self disclosure—therapists implicitly stating that they themselves could have had the same experience—and a validation (Semerari, 2010). In order to offer truly validating interventions, therapists should first imagine themselves in a similar situation and only then empathically communicate their understanding of the patients’ experiences. In this case the therapist tried to recall episodes in which he felt embarrassed or clumsy.

Step 4: Promoting Awareness of the Triggering Factors for Each Specific Emotion

The goal of the next step in our series of interventions was to help the patient achieve a general awareness of the factors triggering the problematic emotions identified when reviewing each single episode. Patients like Roberta can be disinclined to see that problems originate in their own minds and often ascribe the cause of their suffering and poor adaptation to the outside world.

After gaining emotional awareness, patients need to develop an understanding of what thoughts or events elicited emotions. The therapist, therefore, focused on the relational factors eliciting Roberta’s emotions and behaviors. A core aim of a metacognitive-oriented psychotherapy for patients like Roberta is to help them understand how negative emotions, coupled with a theory of mind malfunction, lead them to disengage from the context (Salvatore et al., 2007; Salvatore, Dimaggio, Popolo & Lysaker 2008). We contend that the therapist can try to block the tendency to withdraw as a safety behavior only after such detailed knowledge has been jointly achieved.

In order to do so, a therapist should first summarize the elements of a patient’s discourse internally and hypothesize plausible psychological chain-effect causal links. Both can then engage in a guided discovery of these links:

The therapist’s intervention here led to a remarkable discovery: that a disturbance in self-reflection disorder played a causal role in deficits in mindreading. Being unaware of what she felt and thus confused, Roberta became socially anxious and, as a result, it appears the threat detection system was activated and she grew suspicious and ascribed evil intentions to the others (Salvatore et al., 2011). The therapist then probed for other episodes in which Roberta was embarrassed in order to have a larger data set for identifying what was triggering emotions:

At the end of this exchange, the patient and therapist agreed on the idea that uncertainty was the cause of her confusion and embarrassment, which were in turn leading her to consider others as harboring ill intentions toward her. This is a key aspect of metacognition-oriented therapy for schizophrenia. The therapist constantly promotes the development of the capacity for self-awareness so that patients are able to accept feeling uncertain and then think flexibly about different beliefs that they hold, including delusional beliefs. With this greater capacity, patients might become able first to recognize how their beliefs are just one interpretation of a certain matter and then to grasp the functional significance of those beliefs (e.g. as an explanation for emotional distress). With this procedure it is possible, as illustrated in the passage, to help patients become more able to see how previously held beliefs can be questioned, without the therapist challenging those beliefs in an optimal therapeutic relationship. Therapists are thus able to use awareness of emotional antecedents as an early step to start taking a critical distance from beliefs patients have formed.

Step 5: Validating Emerging Subjective Experience

Sessions should be conducted in an atmosphere involving the validation of a patient’s experiences. Validation involves creating a trusting relationship in an atmosphere of cooperation between peers, in which one can reflect on one’s own experience and the other’s mental states. In the next excerpt, the therapist validates the patient’s entire reasoning/emotion process to avoid fostering a self-as-delusional self-representation. Moreover, the validation should be accompanied by further promotion of the relationship between psychological and environmental variables. In the next excerpt the therapist focused on how unawareness of the minds of both the self and the other was the quickest route to withdrawal and social alienation. Together the patient and therapist reconstructed how the patient distanced herself from others as part of the defense system against perceived social threats. Therefore, therapist both pinpointed event-thought-emotion-action chains and validated this as a human and understandable process when danger is perceived. The combination of a cooperative atmosphere with a concentration on the patient’s actual metacognitive skills led to another moment in which the patient came to acknowledge the negative consequences of her withdrawing.

The validation intervention illustrated above was based on a sharing the difficulties that one occasionally encounters in intuitively understanding the meaning of another’s words, gestures, and facial expressions. For Roberta, these difficulties were pervasive and led her to disengage from the context and to represent others as deliberately malicious. In response to this, the therapist carried out a self-disclosure with a normalizing aim. Self-disclosure is another important way of achieving validation and empathetic attunement. In our approach therapists can point out that they have experienced something similar to the client and also narrate episodes from their own life. But, in general, self-disclosure is not without risks because it opens a window on the therapist’s private life. After these interventions Roberta achieved a level of self-awareness in which she was capable of understanding how interpersonal difficulties triggered paranoia.

The therapist concentrated on this further progress in self-awareness and worked at consolidating it:

In the preceding excerpts we have presented, it is notable that the patient is saying only a few words and the therapist is speaking a lot. The reason for that is that patients like Roberta may have difficulty accessing feelings and translating them in words. The therapist in this phase intervenes with the aim of helping Roberta create a narrative about what is happening in her mind for which she does not yet have words. Once patients have reached a more advanced metacognitive level, it would be assumed that they will construct more articulated and complex narratives about their mental states, and the therapist will be less active and more focused on offer validation of the patients’ new ideas.

Psychotherapy Outcome

After six months of therapy, Roberta was not unhospitalized. She no longer experienced any delusions, disorganization symptoms, or auditory hallucinations. However, her social withdrawal had only improved slightly, probably as a result of the safety behaviors she still maintained to protect herself from social threats.

Regarding metacognition: at the start of therapy Roberta displayed poor awareness of her own emotions, intentions, and desires, and she was unable to recognize the emotional triggers of her tendency to ascribe malicious intentions to the other. Six months later she had made substantial improvements on both counts. She began, of her own accord, to describe more distinct emotional states (e.g., jealousy of her daughter’s friends’ mothers, feelings of inadequacy or happiness). And she acknowledged that her difficulties in interacting with others, whom she perceived as malicious towards her, left her alone and alienated. She also constructed richer narrative episodes, in which there was a complex interplay between distinct emotions and questionable beliefs and she became increasingly able to connect self-narratives to one another, thus identifying recurring life themes. It is worth noting that as Roberta attained higher levels of self-reflectivity, she simultaneously began to become better able to think about the thoughts and feelings of other people.

With this improvement in metacognition, more than just being better able to see delusions as inaccurate, Roberta gained a deeper awareness of herself as an agent in her own life. She was able to grapple with chronic feeling of inadequacy, both from a professional and an existential point of view. She linked these feelings (of her own accord) to experiences since childhood, in which she had felt it was impossible to try out new things because she experienced her mother’s presence as obstructive and invalidating. As her feelings of inadequacy become less pervasive, Roberta was less self-critical and enrolled in a computer skills course.

Conclusions

In the light of emerging research on outcome in schizophrenia, interest has grown in whether recovery can be facilitated by a psychotherapy focused on promoting greater levels of metacognitive capacity. To illustrate what it might involve, this paper has offered an intensive analysis of a single session of metacognitive-oriented psychotherapy in the case of a woman with disorganized schizophrenia. As illustrated in this session, the therapy focused on a patient’s metacognitive dysfunctions and on stereotyped and biased interpersonal relationship schemas, in the context of a constant regulation of the therapeutic relationship and of a validating environment. The session analyzed focused on promoting the capacity for self-reflection, such as understanding the links between disturbing emotions and difficulties in pragmatically understanding other’s minds during communicational exchanges, and considering the ascribing of malicious intentions to others to be a problem. In particular, this patient’s difficulty in pragmatically understanding the intentions underlying conventional forms of communication (jokes, greetings, allusions, etc.)—a difficulty termed disadherence to the intersubjective context (Salvatore et al., 2007)—caused her embarrassment and a feeling of ineffectiveness and inadequacy, which led to social withdrawal.

Our approach, as mutually acknowledged (Fonagy, Bateman & Bateman, 2011; Lysaker, Gumley & Dimaggio, 2011), is similar to the mentalization based approach (Bateman & Fonagy, 2004; Fonagy, Gergely, Jurist & Target, 2002). According to this perspective, individuals with impairment in the capacity for mentalization have difficulty recognizing, describing, and identifying inner experiences and the psychological causes of their behavior, actions, and emotions. Consequently, it is difficult for such individuals to put themselves, implicitly and explicitly, in others’ shoes and abandon their own viewpoint to achieve a sophisticated understanding of what drives others to act, feel or think (Fonagy, 1991). In fact, case studies have been published about patients with schizophrenia who use a mentalization approach similar to the one we advocate (Brent, 2009). In this theoretical and clinical line, our attempt is to make the therapeutic interventions sequence more structured, creating a reproducible hierarchy of interventions aimed at promoting improvement in patients’ metacognitive capabilities (Lysaker et al., 2011).

The therapist worked on the basis of a sequential hierarchy of interventions, i.e. he

All these steps were carried out in the context of a constant, tactful regulation of the therapy relationship. After 6 months of therapy a number of gains were noted in terms of improved community function, the development of a richer personal narrative and the remission of some, though not all symptoms.

Perhaps psychotherapy is a viable way to help persons recapture metacognitive capacity if therapists attend to patient’s actual mentalistic capacities. While this study supports testing the use of metacognitive-oriented psychotherapy to treat schizophrenia, several important limitations need to be pointed out. There has been no specific research into its effectiveness and this is one of the first single cases in which the implementation of the model is described. Replication is needed with a broader range of settings, therapists and patients. Our group is working to create a scale to measure adherence to the key elements of a metacognitive focused therapy and to create a manualized protocol that could be tested in randomized controlled trials.