Metacognitive Reflection and Insight Therapy (MERIT): Application to a Long-Term Therapy Case of Borderline Personality Disorder

Patients with borderline personality disorder have a broad range of impairments that involve prominent, immediate, and long-term threats to wellness. Although a range of skills-based treatments have emerged that successfully focus on problematic behaviors commonly found among people with borderline personality disorder, such as parasuicidal behaviors and resultant needs for hospitalization (1–3) and serious disruption in interpersonal functioning, many people with this disorder continue to experience both a sense of emptiness and a gross lack of fulfilment in life (4, 5). One explanation for these results is that these treatments do not address underlying deficits in the ability to form an evolving integrated and complex sense of self and others and to then use that information to decide how to respond to psychosocial challenges in daily life. For simplicity, we use the term metacognition to describe the range of activities that allow people to perceive their unique cognitions, desires, and emotions and then integrate that information into larger, complex representations of self and others (6, 7). Evidence that deficits in metacognition play a role in borderline personality disorder comes from multiple sources. Persons with borderline personality disorder have been found to have pronounced struggles in reflecting on the ideas they form about themselves and others (8), seeing how others can validly perceive the world differently (9), organizing information in the moment in complicated social situations (10), and using metacognitive knowledge to effectively respond to challenges (11). Persons with borderline personality disorder have been reported to have difficulties noticing their own emotions (12) and accurately recognizing others’ emotions (13, 14) and motives (15, 16).

Paired with this literature, efforts have accelerated to test the effectiveness of treatments for borderline personality disorder that target the ability to think about oneself and others. The most prominent of these is mentalization-based treatment (MBT; 17). MBT refers to the activity of reflecting on mental states as mentalizing, and it posits that mental states are situationally dependent. Bateman and Fonagy suggest that borderline personality disorder is a condition characterized by “stressful experiences in the context of attachment relationships [which] . . . hyperactivate the attachment system and lead to the loss of mentalization” (17). MBT seeks to establish an empathic connection with the patient, validating the patient’s subjective experience, exploring mental states, identifying affect, and thinking about the therapeutic relationship. Ultimately, the goal is to help patients with borderline personality disorder gain the ability to manage painful emotions by developing a secure attachment that makes it more possible for them to think about their own mind and the minds of others. Metacognitive interpersonal therapy (MIT; 18) is another form of psychotherapy concerned with how patients with personality disorder form ideas about themselves and others in earlier stages of development. MIT, in contrast to MBT, considers attachment and metacognitive capacity as separable, and it promotes metacognition by developing a shared formulation of patients’ maladaptive interpersonal schemas and associated emotional and cognitive states, ultimately assisting persons to gain a more complex and accurate understanding of their behaviors.

Although these approaches have shown promise in several trials (19–21) and in rich casework (22), they do not deal as explicitly with long-term recovery as does metacognitive reflection and insight therapy (MERIT). Recovery in the context of psychiatric treatment is defined as the attainment of a personally acceptable quality of life and level of functioning given the constraints of mental illness. It is a concept that has emerged from grassroots consumer movements, longitudinal research, and the long-standing practices found in psychiatric rehabilitation. Recovery is recognized as multidimensional; it involves facets such as self-direction, empowerment, holistic understanding, hope, redefining self, and overcoming stigma (23, 24) that are conceptually and empirically distinguishable from symptom remission (25). Although there is no reason to believe that treatments such as MBT could not promote recovery, they lack formal consideration of issues such as self-stigma and barriers to patients taking charge of their own recovery (e.g., immersion in the sick role).

In contrast, MERIT (26, 27) is an integrative form of psychotherapy developed for persons with psychotic disorders. It has a strong foundation in the principles of recovery and targets interventions to increase capacity for self-reflectivity, awareness of others, mastery, and ultimately decentration. To date, its application to persons with borderline personality disorder has been reported in a single case study of an adult with borderline personality disorder living in a long-term inpatient setting (28). This article describes how MERIT was delivered and led to gains in metacognitive capacity along with personally meaningful movements toward recovery after years of suffering and profoundly poor functioning.

MERIT is guided by five core assumptions and eight therapeutic elements that should be present in each session (29). The five core assumptions are as follows: Recovery from severe mental illness is possible; patients are active agents in their own recovery in all phases of illness; the therapeutic relationship must be nonhierarchical; the experiences of persons with psychosis can be understood; and greater levels of awareness may lead to emotional distress and stigma. The eight therapeutic elements are recognizing and voicing the patient’s agenda; presence of the therapist’s thoughts as part of a dialogue; eliciting narrative episodes; defining a psychological problem; discussing interpersonal processes within the session; evaluating progress; stimulating reflective acts about oneself and others; and stimulating the use of knowledge about oneself and others to respond to psychological problems. These elements are considered guiding principles of the therapy and should be implemented in a flexible manner.

MERIT shares with other metacognitive therapies a view of metacognitive processes as intersubjective and a fundamental need to understand the whole person, including patients’ subjective experiences of themselves and the world. It also emphasizes approaching sessions with a rigorous curiosity about the patient’s experience that appears to mirror what Bateman and Fonagy (17) called a stance of “not knowing.” As with MIT, MERIT differs from MBT in that it distinguishes the knowledge of self and others from the use of that knowledge and does not view metacognitive dysfunction as occurring solely in the context of insecure attachment. Thus, MERIT not only focuses on deficits in reflectivity about the self and others but also explicitly attends to the ability to use that knowledge to respond to psychological problems, which is referred to as mastery. It is believed that the three domains of metacognitive capacity—self-reflectivity, awareness of the other, and mastery—can be detangled, and interventions can be targeted to each domain. MERIT does not conceptualize emotional regulation as a precondition for metacognitive activity but understands the two constructs as mutually influential, such that enhancing metacognition could lead to better emotion regulation and that gains in metacognitive capacity could affect emotion regulation.

To explore the potential use of MERIT to promote recovery from borderline personality disorder, we describe one case of long-term psychotherapy with a patient. We describe how MERIT, through its emphasis on joint meaning-making, facilitated recovery by assisting the patient to evolve a sound sense of personal agency that empowered him to direct his own path to wellness.

Case Illustration

Presenting Problem and Patient Description

Dukas is a Caucasian man in his 50s who was reared with his three siblings in a rural town in the southwestern United States (details of the case and patient have been disguised to protect confidentiality). At age six, after his parents were killed in an automobile accident, Dukas and his siblings moved in with his aunt and uncle and their four children. He reported that his alcoholic uncle was abusive and began to decline after his daughter committed suicide when Dukas was 16. After this event, his aunt and uncle divorced, and Dukas lived with his aunt. His aunt had several romantic partners, and Dukas described a very close relationship with her when she was between boyfriends but being “discarded” by her whenever she was involved in a new relationship. Nonetheless, he reported that in his 30s, he moved into his aunt’s home to be her sole provider of end-of-life care. Family history of mental health problems included substance use disorder of three siblings and his uncle’s alcoholism, likely to cope with depression.

Dukas described his childhood home as full of chaos and abuse. He recalled a time when he hid his younger cousins in a closet to shield them from his uncle’s beatings; he also reported that his uncle had often locked him in the basement when he was “bad.” Dukas said that at times he was paralyzed by fear as a result of unpredictable punishment; he remembered a day when he was a preschooler in which he decided to do nothing but rock in his rocking chair all day to avoid a beating, but that his uncle still abused him. He was repeatedly in trouble for truancy and running away, but he eventually completed high school and joined the Air Force. He served in peacetime and was discharged honorably after serving in an administrative position for four years. He was awarded a small service-connected disability benefit for an ankle injury, which sustained him over the years. He described his time in the Air Force as a time when he was the most successful and responsible. However, when he came home, he resumed his family role as “fragile,” as his aunt had typically referred to him, and returned to a life of chaos. He drifted from job to job, typically having some initial success but eventually being fired.

Dukas never married, considered himself gay, and espoused a previous therapist’s theory that his sexual orientation was the result of his uncle’s sexual abuse, although he later admitted that the abuse never occurred. He had many unsuccessful and stormy relationships. Dukas had never lived by himself and often lived in halfway houses with others. He had a history of heavy cannabis use dating back to high school, and at the time therapy began he met the DSM-5 criteria for cannabis use disorder. When therapy started, Dukas had more than 10 inpatient hospitalizations, generally following suicide attempts, often after the breakup of a romantic relationship.

Case Formulation and Assessment of Initial Levels of Metacognitive Functioning

Diagnostically, Dukas presented with stable personality disorder traits that met full DSM-5 criteria for borderline personality disorder. He experienced affective instability, unstable relationships, impulsive and self-destructive behaviors, intense reactivity to perceived abandonment, the lack of a core sense of identity, recurrent suicidal behavior, chronic feelings of emptiness, and transient episodes of psychotic experiences that occurred when he was emotionally dysregulated (DSM-5). Dukas’s metacognitive capacity was assessed using the four subscales of the Metacognition Assessment Scale-Abbreviated (MAS-A; 27, 30): self-reflectivity, understanding the mind of the other, decentration, and mastery. The MAS-A is an adaptation of the Metacognition Assessment Scale (7).

During the initial stages of treatment, Dukas’s eloquent and open presentation of his use of dysfunctional cognitions, patterns of instability, and fears of abandonment led the therapist to overestimate his capacity for self-reflectivity. For example, Dukas would explain that his black-and-white thinking contributed to problems in interpersonal relationships. Further discussion revealed that Dukas had a superficial understanding of how these problems fit together and affected his life. He could differentiate his cognitions (e.g., he was able to distinguish memories from wishes), but he could only identify extreme emotions and struggled to comprehend his own affective states in a nuanced manner. Similarly, although Dukas was able to recognize others’ basic emotional states, he often could not identify what caused these states or use this information in a masterful way. In terms of decentration, Dukas seemed to experience himself as the center of others’ intentions and cognitions and was unable to recognize that others could validly perceive events differently than him. Regarding mastery, Dukas could readily acknowledge being in distress, which was typically related to various forms of mistreatment by others. He would typically alleviate his distress by engaging in unhealthy and self-destructive acts, including parasuicidal behaviors, substance abuse, risky sexual activities, and impulsive behavior. Dukas’s scores on the MAS-A subscales were as follows: self-reflectivity, 3.5; understanding the mind of the other, 4; decentration, 0; and mastery, 1.

Element 1: Determining the Patient's Agenda

The first element of MERIT is to recognize the patient’s agenda during each therapy session. A patient’s agenda involves what he or she is seeking during a particular encounter. The patient is likely to have multiple agendas, which can be complementary or contradictory, can be within or outside of awareness, and can potentially change during a single session. The primary aim is not the correct identification of a need but rather a joint reflective process in which the patient becomes increasingly aware of mental activities in the form of her or his wants and needs, which could be integrated into a larger sense of the moment, promoting both awareness and agency.

Early in therapy, Dukas was invited to reflect on what he wanted the therapist to think of him. At the start of the session, for example, when he said he feared abandonment and needed to express himself verbally instead of behaviorally, he and the therapist jointly determined that what he actually wanted was to demonstrate to the therapist was that he was a “good patient.” As a result of his previous years of supportive therapy and psychoeducation, he was quite familiar with terms such as black-and-white thinking, dysfunctional cognitions, and need for boundaries. Together he and the therapist reached the conclusion that although Dukas said his initial goals of therapy were to “contain anger, gain self-esteem, have more appropriate interpersonal relationships, and make better decisions,” his primary agenda was to impress the therapist, which, in time, he recognized. Indeed, the therapist was often mistakenly lured into thinking Dukas was already well on his way to recovery and that the therapy she could offer might prove to be the most helpful yet. Dukas also identified as having a victim mentality, stemming from his desire to please his abusive uncle as a child, and he put pressure on himself to be perfect. When he stated that he had nightmares after sessions or that his aunt always saw him as though he was “a piece of glass,” the therapist again discussed with Dukas what he intended; they concluded that his agenda might be to make sure the therapist knew she had to treat him with great care.

Over time, these joint reflections about Dukas’s agenda led to the idea that he came to sessions with the desire to establish that his failures in life were not his fault. Examples of initial comments within which this agenda was embedded included Dukas discussing family members who treated him poorly and his fear of success. Other times, when he seemed to attempt to convince the therapist that all was going well in his life, they jointly reflected that Dukas had two agendas: to fool the therapist and thus feel superior to her and also to make her feel as though she was the best therapist he had ever known. To jointly reflect on these agendas, the therapist had to reject the natural wish that this truly reflected that she had achieved something no one else had because of her excellent therapy skills, and she also had to question the veracity of Dukas’s report of past therapists’ comments. She had to continually question her own ideas and pay close attention to what she felt pulled to do to reduce Dukas’s distress.

After about four years of therapy, the agenda began to shift. Dukas threatened to get a new therapist or to seek services at a different facility because the therapist was not helping him. Jointly this was understood and discussed as Dukas’s wish to make the therapist feel inept and have her assume responsibility for him in session. Of note, they agreed that Dukas was seeking to have the therapist take responsibility, and he responded negatively when the therapist declined to do so. Instead, she validated his perspective by acknowledging his disappointment in the progress he had made and encouraged his agency by having him decide whether and when he wanted to schedule another session. Two months later, he returned for a session and stated that he was not sure what he wanted other than to see whether she was “still there.” Another three-month period elapsed with no scheduled session, and then Dukas returned with the explicit agenda to stop destroying himself. He then slowly began to think about the patterns in his life (which he had previously refused to acknowledge) with the purpose to stop doing things that hurt him and others around him.

In summary, for this element, from session to session Dukas jointly identified with the therapist what he was seeking and, regardless of whether the therapist believed his decisions were the healthiest ones, the two at least jointly saw Dukas as having his own wishes, wants, and desires that could potentially be integrated into a larger sense of who he was as a being in the world. Fundamentally, the dyad thus treated Dukas as an agent and rejected the stigmatizing view that directing his own life was not up to him, no matter his distress or history of poor decisions.

Element 2: Introduction of the Therapist's Thoughts in Ongoing Dialogue

The second element of MERIT requires the therapist to insert his or her own mind into the session in a meaningful way that does not derail dialogue and that allows for reflections about what it is like for the contents of the patient’s mind (e.g., the patient’s agenda) to be known in the moment. Early in treatment, in conjunction with noting that Dukas often sought to conceal parts of the truth, the therapist freely shared her own experience in the moment of not knowing when he was being honest and what he was hiding. She would often playfully ask, “What percentage of what you just said was true?” This often resulted in Dukas either laughing and confessing that he enjoyed being caught or tearfully expressing relief at being understood.

For this element, the therapist established both that she had her own thoughts and that Dukas himself had reactions to that fact. For example, when she wondered whether his global remarks about being depressed were part of him gearing up to self-destruct again and whether she should be prepared to admit him to the hospital, she established that her own mind was fully present in the session and offered a chance to reflect on how Dukas was both reassured and angered by her formation of these ideas. Examples of other thoughts she shared included that his repeated patterns of self-destruction served a purpose for him and that after his acts of self-destruction and consequent loss of apartments, jobs, relationships, and so forth, he was quite good at rebuilding his life and had renewed energy. These examples led Dukas to collaborate more with the therapist and jointly form new ideas. For example, they jointly developed an awareness that Dukas needed chaos in his life to ward off feeling empty and alone and that self-destructive behaviors could be quite enjoyable and exciting for Dukas.

We should note that the essence of this element is not so much to discover material as much as to establish that the patient’s mental states can be viewed from another perspective and that the patient being viewed from that perspective has definite reactions that should be made manifest. Dukas, however, often resisted allowing the therapist to know him, which they reflected on as well. For example, he often described himself in a fragmented way, in a manner often referred to as splitting, in which he was either “good Dukas” or “bad Dukas.” In this instance, the therapist resisted the temptation to join one or the other by doing nothing more than noting the pressure she felt to agree with the view of the day. Other times, when Dukas was overwhelmed with joy or sadness, the therapist often felt pulled to celebrate or soothe him. Instead, she kept her own view viable by remembering the larger pattern of events and sharing them for joint reflection. Thus, the goal was not to stop the splitting but to keep her own boundaried perspective viable and continue to offer Dukas a chance to reflect on how much he did not want her to have her own thoughts about him and the discomfort those thoughts caused in the moment. Over time, this led to his realization that to be honest and authentic with another person was terrifying, but that he was starting to feel more comfortable with it and to feel some power in his own life.

In summary, this element, in conjunction with the first, involved Dukas becoming aware of a host of wants and needs in the moment, allowing those wants and needs to be viewed from another perspective, and ultimately to experience a personal reaction to being understood. These elements thus promoted the emergence of and reflection on mental contents that could potentially be integrated into a larger picture of himself as someone other than a victim and as someone who was responsible and able to manage his life.

Element 3: Narrative Episode

The third element of MERIT requires the therapist to elicit and promote reflection on the patient’s narrative episodes within the flow of her or his life to form a contextualized mutual understanding of the patient as a unique being. Here the challenge was not that Dukas did not offer narratives of his life, but that each was an unchanging, prepackaged account designed to elicit a specific reaction from the therapist. These stories, designed to establish Dukas as a victim and others as malicious persecutors, felt particularly natural to Dukas and indeed rarely portrayed him as affecting the events and people around him. Such narratives included stories in which an older cousin spoiled his birthday by ruining his cake and presents and another instance in which Dukas hit himself on his head with a hammer with reliable caretakers in sight. In response, the therapist asked for more detail and often wanted to know who was present during the events and details about what Dukas did and said. Initially, this spurred longer narratives involving being a loner in school and having no one to sit with at lunch or play with after school. He also talked about a neighbor who helped him with homework who committed suicide when he was a teenager. Dukas discussed his aunt, who had many boyfriends and who, he said, cared about them “more than she did about me” and would only attempt to relate to him when she was between relationships.

In early sessions, one obstacle to obtaining narrative episodes from Dukas was pressure to ignore history and to focus on the crisis of the moment. He was not used to thinking about his life but was instead more focused on problem solving, which may have made him feel better momentarily, but resulted in no lasting sense of who he was as a person or any context in which he could think about his life and behaviors. Responding to this, the therapist noted both that the narrative episodes allowed her to understand and that she also recognized that discussing his life in detail often felt uncomfortable and strange to Dukas.

In time, they discussed the details of narrative episodes to recognize patterns. For example, discussion of past relationships allowed for the joint reflection that each relationship started intensely with passion and hope for love but abruptly changed as Dukas began to see his partner as a tormenter. He would then stay in the relationship and attempt to fix it, ultimately experiencing abandonment and then engaging in parasuicidal behaviors or returning to metaphorically hitting his head with a hammer. These narrative episodes were elicited multiple times, and each time those narratives deepened in terms of detail, demonstrating hints of agency and a more nuanced account of his life. As these stories were revisited, with inquiries about what happened before and after the events in the foreground, Dukas and the therapist jointly agreed that Dukas was masterful at destroying his life in a manner that was thrilling and that he was then equally as masterful at rebuilding his life, only to repeat the pattern. As healthier behaviors began to emerge, narrative episodes allowed for reflection on the strange sense of dissonance he felt in response to not actively destroying himself in the present and instead taking charge of his life.

Element 4: Psychological Problem

The fourth element of MERIT is the recognition of a mutually agreed-on psychological problem. Because Dukas came to therapy with many prepackaged stories, he also had a number of abstract psychological problems that had little meaning when explored. As mentioned previously, these abstract problems were often in the form of statements that he had black-and-white thinking, a lack of boundaries, trust issues, low self-esteem, fear of abandonment, and difficulty expressing anger. Initially, these statements seemed to reflect a genuine understanding of his presenting problem, given how articulately Dukas could express them. However, the therapist observed that they seemed to have no meaning or honest issues for reflection; after Dukas reported them, he would typically return to discussing his latest crisis.

In about a year, as the therapist attended to the agenda, inserted her own mind, and elicited narratives, Dukas’s first recognizable psychological problem emerged: that he felt globally mistreated by others. As they further explored this problem, he also began to realize that when he was alone, he experienced excruciating emptiness. As his understanding developed further, Dukas was able to recognize that feelings of emptiness were related to many of his self-destructive actions. He noticed that engaging in self-destructive behaviors tended to fill him with excitement and relieve the emptiness, yet they also caused him much loss, including homes and employment, from which it became increasingly difficult over time to bounce back. Thus, after five years of therapy, he realized that one of his most central psychological problems was his comfort with self-destruction and fear of how different life would become if he gave up those parts of himself. After nearly five years of therapy, he began to express the belief that he had some choices in his life, and in parallel to that beginning sense of agency, he also began to see that he had some responsibility for the problems he encountered.

As in the case of the other elements, Dukas’s progress was not linear. He was openly ambivalent about giving up habitual ways of managing emptiness. He and the therapist jointly reflected that although self-destruction had negative consequences, it also provoked his family members’ sympathy or attempts to rescue him. At times, he would express that he did not want to “give up the chaos” or that he knew he was making a poor decision about a new relationship, but he was choosing to anyway. Nevertheless, even in these instances, he was able to locate his psychological problems within himself rather than blame others for causing them. He was empowered to make his own decisions regardless of whether they were healthy or not. More important, Dukas was also recognizing that he was responsible for his recovery and that it remained a possibility no matter how uncomfortable and complex it seemed.

Element 5: Reflecting on Interpersonal Processes as They Are Occurring Within Session

The fifth element of MERIT requires that the therapist and patient jointly think about the interpersonal processes that are occurring during the session. Whereas the first four elements assist patients to think about their own agenda, to experience the therapist’s thoughts, and to jointly articulate patients’ psychological dilemmas, this element encourages reflection on the therapeutic relationship itself. Much like his presenting sense of self, Dukas’s early understanding of the therapist was fragmented. They jointly reflected that Dukas often saw the therapist as a cheerleader, someone from whom he might receive lavish praise, a mother about to scold him, or a supportive but oblivious and neglectful listener who could be tricked.

This element synergistically influenced the other elements. Discussions about the relationship in which reflection was occurring naturally led back to joint thoughts about Dukas’s agenda and reaction to the therapist in the moment, and they prompted narrative episodes. For example, the therapist would ask whether she had been the scolding mother he was seeking and how honest he been in session. This led to thoughts about how he had acted similarly in other specific situations. Dukas’s threatening to fire her as his therapist provided the opportunity for the therapist and Dukas to discover together that this stance made him feel more powerful in response to his experience of increasing vulnerability and the anger he felt at not being soothed by her.

Over time, Dukas’s reflections deepened and became more complex as the therapist became more of a unique person and partner in those joint reflections. As an illustration, during one particularly meaningful session, Dukas asked the therapist to say nothing but to just listen. It was his first session after having been briefly hospitalized, and he acknowledged without prompting that he had put the therapist “in the place of having to admit me, because I wanted to be taken care of like a child.” He acknowledged needing to be more honest and feeling guilt for manipulating others to take care of him. He noted that he wanted her to challenge him and was grateful that she had not been providing answers. Dukas further stated that he needed to put the parts of himself together but that he hated certain parts of himself. Thus, in conjunction with the first four elements, Dukas was not only thinking about himself and others in the flow of general life, but he was also thinking about the unique interpersonal context that was happening in the moment, further empowering himself to make sense of and respond to the demands of life.

Element 6: Reflection on Progress Within the Session

The sixth element of MERIT requires reflection on how, as a result of the first five elements, the patient’s mental states are changing; in each session, the patient is asked to think about how the session has been experienced. In other words, this element deals with the effects that thinking about one’s agenda, the insertion of the therapist’s mind, narrative episodes, the psychological problem, and the relationship all have on the patient’s mental states. To offer opportunities for this form of reflection, the therapist asked questions such as “How is the session going today?” “Is it what you expected?” or “Was this at all helpful today?” Dukas initially responded either with global praise or criticism of the therapist, saying she was either completely helpful or useless. In fact, consistent with his lack of agency, it seemed difficult for him to imagine that the session or anything they did jointly could possibly affect his mental state. Slowly, through focusing mostly on negative experiences, Dukas and the therapist discussed how her failure to provide solutions left him uncertain and confused.

After five years of therapy, they had richer discussions about what Dukas needed and what he thought he needed to do both within and outside of session. He noted that he hated to cry, but he could reflect that as a result of crying in session, his mental states had changed and that he felt relief. He also reflected that he delighted in tricking the therapist and it was terrifying to be honest; however, being honest led to an odd sense of accomplishment and relief. As a result of these reflections, Dukas increasingly took charge of sessions and formed ideas across sessions about how his mental states were changing. Quite compellingly, as he chose to engage in less self-destructive behaviors, he identified his surprise at his comfort and lack of distress: “Being like a normal person. . . . I’m beginning to like boring; I can’t believe it.” In addition, he remarked that it was odd for him to fear “losing everything again.”

Element 7: Stimulating Self-Reflectivity and Awareness of the Other's Mind

In the seventh element of MERIT, therapists assess patients’ metacognitive capacity for self-reflectivity and awareness of others’ minds in the moment using the MAS-A. They then tailor interventions accordingly. When the therapist is promoting all the first six elements, he or she should offer thoughts that match the patient’s metacognitive level and consequently are not beyond the patient’s grasp. In terms of metacognitive capacity, Dukas began therapy with the capacity to recognize different mental activities, but he struggled to name emotions that were not extreme states of distress and pleasure or to experience the presence of having conflicting emotional states. Accordingly, early interventions did not assume he could name his emotions, and considerable time was spent just trying to acknowledge all the contradictory thoughts in his mind. This precluded the therapist from trying to link thoughts and feelings together because emotional states were just an abstraction to Dukas. Once Dukas could experience and reflect on his emotional states in a more nuanced manner, the work focused on integrating cognitive concepts, and there were discussions about the ideas he had about himself and how he formed them. Beyond that, discussions focused on the notion that how and what he needed was not the same as what reality provided. He was able to think more compassionately about himself as someone with different facets, including a mischievous sexual side and a caretaking side. He could also describe and tolerate the experience of deep and enduring sadness, rage, and a wish to lash out violently. He then began to think about specific life events, identifying the complex forces that motivated him to act, the self-destructive choices and reasons for such choices, and similar patterns present across time.

In terms of reflecting on his sense of others, Dukas began therapy able to notice others’ emotions, but he struggled to understand intentions or more nuanced connections between what others thoughts and felt. Thus, intervention began at the level of wondering what others intended or wanted to communicate to him. It was interesting that as he began to see himself as having different facets, he began to see others as having their own range of desires. Although early on others were generally present in his narratives as sources of frustration or gratification, as he began to recognize how his life narratives were integrated and as he identified his repetitive self-destructive patterns, he became more curious about others in a genuine manner.

As Dukas became more able to form complex ideas about others, the therapist found herself using more self-disclosure. Information about the therapist was used to scaffold Dukas’s ability to understand himself. In other words, now that Dukas was able to think about the therapist in more complex ways, he could use unique information about her to think about himself. As an illustration, she related to Dukas her personal experience about how being responsible was at times no fun and how living alone could be challenging but rewarding, which validated his experience and provided a model for integrating seemingly conflicting information. It also helped him to think about his daily experience as well as the experiences of others in his life. He began to talk about relating to others in a manner in which he could see their needs and be curious about them. He could see a friend as an individual with not only thoughts and feelings but also a complicated life story. For example, he discussed a recent friendship he had formed and focused on facets of his friend that interested and intrigued him. At this level, interventions focused on thinking with Dukas about how his friend’s thoughts and feelings interacted in the moment as she, for example, faced a challenge at work. Similarly, when discussing his uncle, late father, and late cousin, interventions assisted Dukas to form complex and integrated ideas about these people and then to reflect on those ideas.

Element 8: Stimulating Mastery

The final element of MERIT parallels the seventh and calls for therapist interventions that promote mastery, or the ability to use metacognitive knowledge to respond to psychosocial challenges in a manner that considers the patient’s current capacity for mastery. Whereas Dukas started therapy without even a coherent account of a psychological problem, over time he demonstrated many gains in this capacity. Early in therapy, interventions were focused on identifying general emotional distress. The major barriers to identifying this distress were Dukas’s many manifest concerns; that is, his comments about having “no boundaries” or “black-and-white thinking” were really empty phrases that masqueraded as meaningful expressions, and he provided no meaningful narratives that could serve as a context for naming the dilemmas he was facing. However, as the work focused on exploring the narratives of his many self-destructive acts coupled with reflections on Dukas’s agenda in session, he began to express that his self-destructive behaviors felt good because they relieved a form of distress that he finally started to label. The labeling of distress, however, was part of the fourth element and involved development of self-reflectivity, which is captured in the seventh element. Development of mastery, by contrast, calls for joint reflection on how the patient responds to distress. In the beginning of therapy, it was determined, by thinking backward from his distress, that Dukas’s destructive actions, such as substance use and risky sexual behavior, were a means to calm himself and that was all he knew to do when distressed. As his self-reflectivity grew and he was stimulated to think more about how he had responded to emptiness during his life other than through self-destructive behaviors, he identified sleeping as something he used to deal with emptiness. He could see that although this was quite passive, it was an alternative to self-destruction, which he openly said he was quite ambivalent about letting go.

As described earlier, in the fifth year of therapy, when Dukas returned to psychotherapy after his therapist declined to be responsible for his attendance, he declared a significant decision to stop engaging in self-destructive behaviors. Dukas stopped using cannabis and has maintained his sobriety since. He was, however, unwilling to give up risky sexual activity. Nonetheless, he recognized that he was seeking an additional strategy to reduce his intense emptiness—reflecting and thinking with his therapist during sessions. This naturally led to conflicting feelings about the therapist when he felt pain that did not diminish in her presence. These conflicts, however, were expressed verbally and collaboratively, whereas previously he had threatened suicide, which forced his therapist to have him hospitalized. In fact, in the fifth year, he had one hospital stay, and only one in each of the next two years after that. In contrast, he was hospitalized five times during the first three years of therapy and four times during the fourth year of therapy. As an explanation for his decrease in hospitalizations, he would often comment in sessions that he chose not to self-destruct and instead would go to sleep to tolerate his unbearable feelings of emptiness. Here he seemed to take another step forward in terms of mastery because he chose to inhibit a specific behavior. During this time, other markers of recovery emerged, including holding a part-time job in a grocery store and maintaining his own apartment.

Although he continued to occasionally engage in risky sexual acts, they generally became less dangerous, and he realized that he had become empowered to take specific, more adaptive actions to alter his own intolerable internal states while inhibiting his long-standing patterns of self-destruction. Joint reflection emerged about the danger of an impending act of self-destruction and on how Dukas could fill the emptiness in a healthier manner, such as by reminding himself that he wanted to maintain his employment and by telling himself that he could tolerate and survive the emptiness. When he did disclose negative actions, he came to the session with the expectation that he and the therapist would think about the circumstances of the narrative, rather than that he would receive criticism.

When Dukas developed more capacity for mastery, new dilemmas emerged. Feeling more responsible for his life caused him a new kind of terror and discomfort. He stated that when others viewed him as “having it together,” he felt anxiety because it was different from his more comfortable role of patient or victim. Interventions were then aimed at challenging Dukas to think differently about himself, and he began to use knowledge of himself to regularly manage his daily emotions. The therapist had to be patient during this time and accept that gains were often followed by regressions. After having a consistent job for close to seven years, he suddenly found himself in conflict with his supervisor and quit precipitously. Soon after, he was hospitalized briefly after making superficial cuts on his wrist and then stated that he did not want regular therapy because the therapist was uncaring and did not want to challenge his thinking. Three months later, he was back in therapy, and his gains in mastery persisted. He was working, having sought a new job himself, and he was again using his knowledge of himself to manage the struggles of daily life. He explained, “I just need to be average. . . . I’m just a lonely guy trying to make it through life like everyone else.” He shared that he still has suicidal thoughts at times, but “I can work through it myself, I’m stronger than I think. . . . For the first time in my life I’m making better decisions and I feel proud of myself.” At one point, he brought up the narrative of hitting his head with a hammer and said that, metaphorically, “Maybe I’m finally stopping.”

Outcome and Prognosis

After nearly 14 years of therapy punctuated by several breaks, the therapist-patient dyad continues to think about Dukas and his life. After 10 years, he began to see himself as being in a state of recovery. He has now maintained his own apartment and employment for years, abstained from cannabis, and formed stable friendships, and he has not had a hospitalization for seven years. He is not without pain, however, and still has occasional fleeting thoughts of suicide, but he has sustained a realistic and compassionate view of himself.

There is no way in a case report to determine what might have led to change and recovery. It could be common factors within psychotherapy or even something that might have happened just as a result of time itself. Nevertheless, in this article we hypothesize that psychotherapy bolstered Dukas’s metacognitive capacity, thereby empowering him to make sense of a chaotic history, characterized by substantial pain and self-destruction, and to direct his own recovery. Indeed, Dukas’s capacity for metacognition was observed to increase. In terms of self-reflectivity, he developed the ability to recognize nuanced emotions, to perceive his thoughts as fallible, to acknowledge that his life had not turned out the way he had necessarily wanted it to, and to recall his patterns when faced with a psychological challenge. The chronology of his improvements suggests that his understanding of the other built on his understanding of himself; he has developed the capacity not only to recognize others’ affect, but also to think about their perspectives in the context of his knowledge of their history, preferences, and personalities. His gains in decentration have allowed him to tolerate not being the center of another’s world, to acknowledge and appreciate others’ perspectives, and to consider how others’ views may have formed. Finally, he has gained in mastery, which seems to have affected his recovery the most. He actively changes his thinking when he notices familiar unhealthy feelings, because he has learned what his patterns are and feels able and empowered to make healthier decisions. Translating his recovery into MAS-A subscale scores, by the end of therapy Dukas had moved from scores of 3.5, 4, 0, and 1 on the self-reflectivity, understanding the mind of the other, decentration, and mastery scales, respectively, to scores of 9, 8, 3, and 7.

Some reflection on the potential uniqueness of this treatment and its shared conceptual approach to treating serious mental illness seems necessary. Consistent with Fonagy et al. (31), MERIT shares many facets in common with mentalization approaches, including a focus on episodic memory and offering a safe interpersonal environment in which therapists create alternative perspectives on mental experiences while using “normative understandings of behavior rather than theory driven understanding of behavior.” The therapist in this case also used an approach that considered the patient’s processing capacity. As illustrated in this case, though, MERIT may be unique in its focus and emphasis on recovery in at least five ways.

First, MERIT is explicitly rather than tacitly sensitive to stigma and the destructiveness of assuming the sick role, which persons with mental illness often feel pressured to accept. Second, MERIT places a strong emphasis on detecting and understanding the purposes of the person’s behavior (both within session and out in the world), and these purposes are continuously discussed and made manifest. Third, the domains of metacognition are detangled in MERIT, thus allowing for a sharper emphasis on mastery, placing both decision making and meaning-making squarely in the hands of the patient, which then again explicitly makes recovery a matter of self-direction. Fourth, MERIT assumes that phenomena such as emotion regulation and metacognition can bidirectionally influence one another; one is not necessary before the other can occur. Fifth, MERIT is integrative in nature and can be adapted by therapists from multiple perspectives, whereas an MBT therapist must have some degree of fluency in psychodynamic theory.

This case illustration has notable limitations. As stated previously, it is a single case, and no claim can be made that changes were necessarily the result of particular procedures. More work is needed with formal assessments of metacognition and psychopathology over time in both case studies and controlled trials of this treatment. It is important to note that this case was studied over many years, and it is, therefore, unclear how useful this treatment might be in settings that offer shorter time commitments. Future studies might continue to explore the interplay of different forms of metacognition assessed in this work.