Metacognitive Reflection and Insight Therapy (MERIT) for Persons With a Schizophrenia Spectrum Disorder and Interpersonal Trauma

Contemporary research has suggested that making meaning and developing a robust sense of self are contributing factors to recovery from schizophrenia (1). Research has demonstrated that many people with schizophrenia have experienced a significant loss of previously held capacities to think meaningfully about their lives and that individual psychotherapy can play a role in metacognitive growth by stimulating and reforming increasingly complex ways of thinking about the self and others (2).

Metacognition is a psychological function that consists of a spectrum of mental activities that involve thinking about thinking. It refers to mental activities ranging from discrete acts in which people recognize specific thoughts and feelings to more synthetic acts in which an array of intentions, thoughts, feelings, and connections between events are integrated into larger complex representations (3, 4). It also represents how individuals use knowledge of the self and others to form ideas about daily challenges.

Research has suggested that persons with schizophrenia may experience metacognitive deficits and thus struggle to integrate information into a rich sense of self and others and to use knowledge of past and current events to master psychological and interpersonal distress (5). In fact, multiple studies have linked metacognitive deficits with lower levels of intrinsic motivation, functional competence, sense of recovery, therapeutic alliance, and ability to reject stigma, as well as more severe negative symptoms (5, 6). In addition, research has proposed that metacognitive deficits can also act as a barrier to adaptive responding to trauma (7), and more specifically, studies have linked lower levels of self-reflectivity and mastery to greater overall experiences of distress in individuals who have experienced trauma (8).

One implication of this work is that metacognitive deficits can serve as a novel treatment target (6, 9), and individual psychotherapy that seeks to promote subjective domains of recovery may consider interventions to stimulate previously held capacities for reflection. Accordingly, Bargenquast and Schweitzer (10) have reported positive effects of an open therapy trial using metacognitive narrative psychotherapy. Additionally, a randomized controlled trial of metacognitive reflection and insight therapy (MERIT) is now underway in the Netherlands (11). Recently, the investigators conducted a pilot study to explore the feasibility of a shortened version of MERIT for persons diagnosed as having schizophrenia (12). The results suggest that there is a pattern of improvement in metacognitive capacity, with nonsignificant moderate-to-large effect sizes obtained, and that persons with schizophrenia are receptive to an approach that emphasizes intersubjective processes.

More specifically, MERIT seeks to promote synthetic metacognitive capacity and requires a focus on reflection itself (3, 4). As such, the therapist using this therapy cannot rely on teaching skills or on guiding clients toward predetermined or ostensibly more proper understandings. MERIT is informed by psychodynamic, humanistic, interpersonal, and cognitive perspectives and calls for a consultative and nonhierarchical process in which clinicians and clients think together. For example, the therapist is encouraged to share his or her own thoughts, including ideas about the potential dynamics occurring within the session, and to elicit feedback about these ideas to stimulate clients to think about their ideas of themselves and others. In this way, MERIT is a departure from many of the predominant skills-based approaches. Given the complexities that will persist as two individuals begin to think together and relate as unique human beings with fallible ideas, this approach demands continual self-reflection in part by the therapist.

Regarding technical aspects of treatment, MERIT operationalizes metacognition in schizophrenia as a hierarchical capacity and suggests that interventions to stimulate metacognitive activity should be based on the client’s current level of metacognitive functioning (13). For example, clients with lesser capacities will need interventions to assist them to master basic capacities before attempting more complex ones. MERIT calls for eight interrelated processes to occur within every session (14). These processes include positioning the client’s agenda as primary, sharing of the therapist’s thoughts without disrupting dialogue, eliciting a narrative episode, defining a psychological problem, discussing interpersonal processes occurring in the session, evaluating the sessions, stimulating reflective activities about the self and others, and finally, stimulating thoughts about how best to understand and to respond to psychological and social challenges.

Recently, the elements of MERIT have been applied and demonstrated in a series of case studies. These case studies have demonstrated that individual psychotherapy that aims to enhance the client’s capacity to form complex ideas about the self and others may facilitate increased metacognitive capacity of persons with schizophrenia (15–20). This casework to date, however, has been limited in that it has not emphasized additional considerations, such as profound history of trauma and schizophrenia, when working to incorporate these elements with persons who have prominent difficulties in understanding the self and others. Accordingly, this article presents a case study to demonstrate the application of MERIT with an individual who has a diagnosis of schizophrenia and a history of childhood and military sexual trauma.

First, we provide an account of the client’s life and a case formulation that emphasizes his metacognitive capacity at the onset of psychotherapy. We then describe how principles of MERIT were applied in this case. We review therapeutic challenges faced during the course of treatment and special considerations that arose as the client explored new ideas of himself and others and made interpersonal contact with the therapist. The client provided signed permission to use case material for these purposes, with the understanding that any personally identifying details would be disguised to protect his privacy.

Case Illustration: Geert

Client Description

Geert is a Caucasian man in his 40s who was raised by his mother and grandfather in a rural southern town in the United States. He describes an unimaginable history of victimization. He was sexually abused by his mother and witnessed his younger brother being molested by relatives. He explained that his mother’s behavior eventually led his grandfather to gain custody. He recalls fond memories of his grandfather, including working on cars together and playing baseball, although he has since lost contact with him.

He describes feeling closest to his brother growing up, elaborating that he did not interact with others in the neighborhood or at school. Geert indicated he had difficulties making friends and fitting in with peers, who often bullied him for being “different.” In high school, his social difficulties continued, and he started using cocaine. He formed his first significant romantic attachment and married just after graduating high school. He then enlisted in the military, and he recounts being raped by an officer. Geert describes this event as haunting, especially because it has profoundly affected the way his grandfather views him.

He began to experience what appear to have been early symptoms of psychosis, including bizarre and disorganized behavior, and he was eventually hospitalized on a psychiatric unit near the end of his military service. Shortly after, he lost contact with all his family members and his wife; he found himself traveling across the country with little sense of direction. It is difficult to discern a clear account of the subsequent years.

Prior to seeking services at the medical center, he appeared to be transient, living in and out of shelters and finding occasional work. He describes differing accounts of feeling confused while at work and frequently leaving without explanation. Geert stated he has been involuntarily hospitalized more than 30 times while living in the community. In the months preceding referral to therapy, he was assisted by hospital staff in obtaining independent housing. Just after moving in, however, his case manager reported to the treatment team that Geert was exhibiting increased disorganization, delusions, and hallucinations. Geert was preoccupied with the belief that the devil had orchestrated witches to torment, kill, and bring him to hell. He heard planes landing on his roof and witches dressed as soldiers tapping on his windows. The witches were stealing his thoughts and delivering them to the devil, and although he never saw these intruders, he spent countless hours running from window to window to find them. He was hospitalized on a psychiatric unit after he broke into a local store thinking he could find one of the witches there.

With his symptoms at a moderate level, Geert was discharged back to his apartment and prescribed a standard dosage of a second-generation antipsychotic medication. Despite adherence to medication, he remained preoccupied with delusional ideas, exhibited bizarre behaviors, and had little sense of personal agency. He again experienced auditory hallucinations of the devil’s agents in his apartment, eventually leading to hospital stays on two additional occasions within that same month. Because he had difficulty attending to his basic needs, his treatment team worried about his ability to live independently and considered a residential care facility for persons with persistent mental illness as an option. It was recommended to him that he participate in weekly individual therapy.

The psychotherapy described below began during the later phases of his third hospitalization and continued weekly for seven months. During Geert’s first meeting with the therapist (JH), he seemed jumbled and distracted by internal stimuli, making it nearly impossible for the therapist to hold a conversation with him. He reacted to any interpersonal contact or connection with the therapist with intense fear and emotional distress, visibly trembling in his chair and unable to look at her. The only problem he could identify was that witches were breaking into his apartment. Discouraged that the psychiatrists did not believe him, he was likely left feeling confused, misunderstood, and alone.

Case Formulation

Diagnostically, Geert’s clinical presentation met full criteria for schizophrenia. He experienced auditory hallucinations, delusions, and negative symptoms, including emotional disinterest in others, none of which were linked to a major affective illness or medical condition. No current drug or alcohol use was noted. He tended to see the world in a relatively idiosyncratic manner, leading him to integrate unrelated thoughts, objects, and events in unlikely and bizarre ways. These unique experiences impeded his understanding of others’ intentions and needs and made it difficult for him to fully engage in life and relate to others.

Overall, his life appeared to have been profoundly affected by his illness. In addition to the effects of prominent positive symptoms, he was withdrawn and unable to motivate himself without guidance from his case manager. Geert was not pursuing work, nor relationships, and he was virtually unable to see himself as an agent in the world. He struggled to communicate a robust account of his life and had trouble identifying and reflecting on differing aspects of himself. Outside of symptomatology commonly associated with schizophrenia and trauma, these difficulties are conceptualized as a reflection of metacognitive deficit.

Deficits in metacognitive capacity were assessed with the Metacognition Assessment Scale-Adapted (MAS-A; 4, 21). The MAS-A is an adaptation of the Metacognition Assessment Scale (4), developed in collaboration with the original authors for the study of narrative samples. The MAS-A contains four scales that reflect different forms of metacognitive activity: “self-reflectivity,” the comprehension of one’s own mental states; “understanding the mind of the other,” the comprehension of other individuals’ mental states; “decentration,” which is the ability to see the world as existing with others having independent motives; and “mastery,” which is the ability to use knowledge of one’s mental states to respond to social and psychological dilemmas.

In terms of awareness of his own mental states, Geert was able to recognize that he had thoughts that were his own, but he struggled to identify, differentiate, or understand the different cognitive processes within his mind. For example, he could recount memories, yet the details seemed scripted and one-dimensional, and he was unable to reflect and incorporate them into a rich and storied sense of self. He had trouble distinguishing between thoughts of reality and fantasy, reflecting on needs and desires, and planning for the future. In addition, he possessed limited ability to understand himself as an ever-evolving being with thoughts that are subjective and fallible, and he struggled to define and distinguish among a wide range of emotions. For instance, while he readily expressed anger, he became confused by moments of potential contentedness and reverted to talking about times of seeing the devil and memories that embodied the self as betrayed and controlled by others. Feelings of guilt and shame were especially foreign for Geert.

The mind of the other was an even more difficult concept for him to understand. He struggled to know that others had autonomous thoughts and feelings that belonged uniquely to them. For example, he had little-to-no sense that the therapist had her own agendas, memories, or hopes for him. Geert believed she was there to punish him in cahoots with the devil and witches. Although he could distinguish one person from the next, he saw no individual as having any mental characteristics that distinctly differed from others. He attributed his own thoughts to people around him and made general references about people being part of a large system that was set in place to deceive him.

As assessed with the decentration scale of the MAS-A, Geert appeared to experience himself as the center or cause of all meaningful activity. He was unable to see that a larger, complex social world existed beyond himself. For example, he had no sense that the therapist had relationships to people who were not directly linked to him and little sense that she had encounters independent of the hospital where they met. Instead, he experienced grave paranoia and interpreted all events around him as having special meaning. He held delusions that led him to see everything in reference to his persecution. For example, he commented, “I’m here because people want to ruin me… put me into a home, tell me this is what I deserve, and send me into the ground.”

In regard to mastery, Geert was able to express distress related to having the devil send witches to his home, yet he struggled to plausibly explain this concern. When he heard the doctors say the witches were hallucinations, he disagreed, stating, “I am tormented, though, and if they just left me alone, my life would be all better.” Overall, he attributed his problems to an external source, and thus, he was unsure how to effectively use knowledge of himself, others, and the world to effectively cope with distress.

Course of Treatment

Element 1: the preeminent role of the patient’s agenda.

The first element of MERIT calls for the therapist to determine and understand the client’s agenda. The agenda refers to the client’s wishes, hopes, desires, plans, and purposes that he or she brings into each session (21). It is understood that a client may have multiple agendas and be more or less aware of those agendas and that these agendas may continually evolve during a session. The goal of this element is for the client to become more aware of his or her own wishes, desires, and intentions.

Geert’s agenda in the beginning of therapy was unclear. When asked why he had come, he responded that his case manager brought him because the psychiatrist said he needed help. His intentions were driven by what he knew as forces out of his control. He was unable to identify any psychological problem besides distress that the devil’s agents were in his home. As a default, he started by telling the therapist the main points: he was wrongly treated in the service, betrayed by his family members, the devil was out to further torment him, and now he had to go to a home for “schizophrenics.” When he spoke, Geert showed obvious discomfort as his body uncontrollably shook and he stared at the door. The therapist felt overwhelmed and restless herself.

She listened closely to what he said, keeping in mind that each person is an active agent who comes to a session with his or her own wishes, needs, and intentions. Yet, the therapist remained uncertain of what Geert wanted. She did, however, notice an urge to supply structure to the session to alleviate her own anxieties and a wish to educate him about stigma. She resisted and instead reflected, “Your doctor has thoughts about you coming here. I’m curious about your ideas and what has been on your mind.” Confused, he reverted to his default and talked more about his experiences with the devil.

During the first few months, Geert continued to discuss his life in a scripted manner, restating the same details from session to session as if he had forgotten what he previously told the therapist. Each meeting, he spoke with increasing conviction about how his life had changed since serving in the military and how no one could fix what had happened to him. Because this statement was becoming a clear point of reflection related to his agenda, the therapist said, “You started the session off last week with a similar thought. You wanted to remind me.” Alternatively, he might have been expressing a hope that the therapist would say something that would help him to think about it differently, or perhaps he held a need to restore his sense of dignity. The desired outcome, though, could also have been linked to a wish to have the therapist feel inept and unable to help, in an attempt to decrease his own distress associated with feelings of being broken. He assured her that he did not remember the previous session. The therapist accepted that the conversations would be kept scattered and the agenda would remain unclear.

The therapist continued to emphasize the idea of mutual exploration. Eventually, she noticed that outside of memories that depicted him as betrayed and controlled by others, he became confused and changed the topic back to something more known. Consequently, the therapist ventured the thought that he wanted to represent himself as defective to keep people at bay. In other words, part of his agenda was to stay safe from the distress caused by interpersonal relatedness, which had been associated with longstanding confusion and unbearable pain. On another occasion, Geert noted he wanted to test whether the therapist could withstand the kinds of thoughts he had and tolerate him as a person who typically does not know how to connect to others. Thus, what emerged was a wish to be able to be close without being rejected and a desire to lessen associated feelings of shame and inadequacy.

Geert had multiple agendas over the course of treatment, which were often not readily made available in a nuanced and detailed fashion. The therapist was frequently tempted to follow utterances that might have distracted from his true agenda. She worked to track changes in the activity of his mind to stimulate him to think about his underlying ideas, intentions, wishes, and plans. With time, Geert noticed when he trailed away from moments of connection, and at the end of treatment, he acknowledged an ultimate wish for the therapist to reject him as others had in the past.

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 to promote active dialogue and to encourage collaborative thinking (13). In the same vein as in the first element, it was a daunting task for the therapist to share her own experiences without derailing the dialogue and overturning Geert’s agenda.

Given his history of sexual trauma and limited ability to understand the mind of the other, it was especially difficult to gauge the degree of trust established at any given point and to understand how the therapist’s words would be interpreted. Early attempts to insert her thoughts into the session resulted in blank, piercing stares from Geert. This made for an unnerving silence and left the therapist wondering about what she could do differently. Again, she felt positioned to supply structure to the conversation and relieve the uneasiness present in the room. Although uncomfortable, the therapist maintained the stance that it was most important to keep Geert’s agenda first and foremost and to offer thoughts and add speculations as an interested listener.

As Geert continued to share ideas about devils and witches, the therapist attempted to know him as a person having a delusion rather than as a person who should see reality more accurately: “You are consumed by thoughts about the devil” and “As you talk about your experiences with witches, a thought comes into my head. Tracking them down must be exhausting.” She heard him react to these comments by talking about when others responded to him as if he was someone who needed guidance, which left him feeling not only that he could not trust his own mind but also helpless. He described how his neighbor, for example, responded to his thoughts about the devil by telling him he should take a bubble bath and get a new prescription to feel less anxious, while his doctor encouraged him to move into assisted living.

Consistent with recent work on developing and maintaining an open interpersonal stance (22), the therapist realized there were two temptations to overcome and became cautious about the possibility of falling into these anticipated roles. First, she felt positioned to be a minister of comfort and give Geert strategies to help reduce his distress, as if he was a fragile being who could not bear his own pain. Second, she noticed her desire to take charge and tell him what thoughts should be in his mind. To make matters more complicated, Geert was unsure about the purpose of reflection and was confused by the idea of sharing just to share. The therapist reflected, “Talking with me puts confusion in your mind.” He countered, “Well, what do you think? You’re the expert and know best.” Here, the therapist noticed a pull to give him advice and guide him back to wellness; to do so, however, not only would have perpetuated the idea that the therapist does know best but also would have left him with little about which to reflect. To prevent herself from responding in a way most familiar to Geert, she stated, “You wish I had all the answers, and you are surprised I do not.” By maintaining an open stance and sharing thoughts congruent with her own internal framework, the therapist communicated ideas that were fallible and unique to her to promote an active dialogue and encourage collaborative thinking.

The therapist did not challenge Geert’s perception of reality, nor did she view him as someone who needed knowledge and should be enlightened. Geert was thus—by the fourth month of therapy—able to accept her thoughts without his own agenda being shut down or their dialogue derailed. He shared new uncertainties about the reality of his experiences with the devil, and he considered the idea that the therapist was her own being with autonomous thoughts. He asked, “What is in your head?” His interest in the therapist’s mind was supported by increasingly complex reflections, which included, “You think I have thoughts, but it’s unclear what they are” and “I think about what you were like in high school, and what hopes you had for the future.” As time progressed, he deliberated about the possibility that the therapist existed in a world outside of his own. He commented, “What do you do when you get home? I figured you watched TV because that is what I do.” Again, the therapist reinforced this interest and used self-disclosure to further stimulate decentration, “I walk my dog, I make dinner, and sometimes I go to the movies with a friend.” This self-disclosure ensured that the sessions were conversations between two humans, who coexisted in a social world and had differing experiences and perspectives. At the end of psychotherapy, Geert no longer thought it odd to engage in a shared dialogue and think together about his life.

Element 3: the narrative episode.

This element requires therapists to elicit and think with clients about narrative episodes so as to form a contextualized mutual understanding of clients as unique beings in the social world (23). This shifts the emphasis from quickly forming abstractions about clients to exploring the complicated interwoven events of their lives. The goal is not necessarily to create a perfect narrative, but rather to stimulate thought about the representations that clients hold of themselves and others, to situate those evolving representations in the larger social world, and to think together about how that knowledge can be used to cope with psychological problems.

At the beginning of therapy, Geert was unable to articulate his own intentions and seemed to have a limited storied sense of his life. His memories were scattered, tended to be stereotypic and without rich detail, and reiterated themes of being violated and controlled by others. For example, he recounted stories as if he were reading from a movie script with few scenes, and it was evident that questions asked by the therapist outside this framework left him feeling off balance and defenseless. He tended to respond by revisiting how unfairly he had been treated and changing the subject back to intruders being in his home. Whether due to a lack of the trust in the therapist, a metacognitive deficit, or emotional distress associated with interpersonal relatedness and past traumas, he seemed to have no memories of events outside of this storyline or be able to form thoughts that were not about the devil and witches.

With an appreciation of how difficult it was for Geert to provide a narrative about his life, the therapist tried to provide a scaffold to enable him to participate in this activity early in the therapy by explaining her intentions: “I have learned a lot about witches being in your home, but I don’t know anything about you.” She encouraged him that it was an opportunity for them to think together about his life and make meaning of his past and present experiences. She asked specific, detailed questions that focused his attention toward the present moment, such as, “What do you read on my face?” This prompted him to confess that he was uncertain about the therapist’s mind but considered that her furrowed brow meant she did not like him. In response, the therapist reflected that perhaps he felt unsafe talking with her, and inquired about past moments when he experienced something similar, “I wonder if this brings to mind another time you were uncertain about others?” These interventions prompted him to discuss several episodes related to his experiences in middle school and on family vacations. He shared, for instance, a time he felt disappointed after a close friend made fun of him in front of the class. Moreover, as this event was revisited, across many sessions, he disclosed new reactions and ideas, including the thought that perhaps his friend was enraged after Geert pushed her off the playground slide for trying to give him a hug.

By connecting present moments to other events in his life, not only did he start to integrate previously fragmented events into a larger picture, he also began to think about himself in a dynamic manner and with agency. This process, however, bred an overt wish in Geert for things to stay scattered. Geert started to see himself as an active player in a complex web of life events, which led to unbearable pain. Thus, a deeper psychological problem had emerged, which will be discussed in the next element.

Element 4: the psychological problem.

The fourth element of MERIT is the recognition of a psychological problem, which is described as a goal, need, wish, or desire that is perceived and experienced as unmet or frustrated. The aim is mutual reflection upon the client as a being who is experiencing a common human problem (16). In the case of Geert, detecting a psychological problem was a complicated task. With an extensive history of acute hospitalizations, difficulty trusting others, paranoid interpretations of the events around him, and restlessness during sessions, the therapist often felt pulled to soothe him. To follow this lead and focus on diminishing his current distress, however, would have prevented the therapist from gaining insight into his underlying psychological processes. Instead, the therapist had to avoid at least one crucial misunderstanding, namely that Geert’s psychological problems were his symptoms. She had to see his symptoms as fitting into a broader spectrum of human experience.

As therapy progressed, he spoke of feeling conflicted, having both a desire for connection and reservations about new people. Through consultation and personal reflection, the therapist thought of times when she had had similar psychological dilemmas. These reflections allowed her to not only name but also empathize with the psychological and social problems that were emerging. With time, Geert recounted more narrative episodes, which often portrayed a deeply rooted sense of being unworthy of love.

Geert started to notice that he avoided interpersonal contact for fear of being known, predicting that others would reject him. He admitted, “I’m having a memory of a time I don’t like to think about. I want to tell you, but I’m afraid you won’t meet with me anymore.” Thus, a deeper psychological process had surfaced. His need for unconditional love and acceptance had been frustrated, and even worse, ideas that it was his fault left him feeling guilty and remorseful. In the sessions, it was established that he was someone confronting social and psychological challenges and that he suffered in ways common to all humans.

Element 5: reflecting on interpersonal processes as they occur within sessions.

The fifth element of MERIT requires that, in addition to thinking about the client’s life, there is recognition of the interpersonal processes that are occurring during the psychotherapy session. This recognition involves joint awareness that any thinking about the client is happening in an interpersonal context, which itself can be reflected upon. This may have been the most difficult element to achieve with Geert, and yet, arguably one of the most important elements addressed during the course of psychotherapy.

At the beginning of treatment, while he knew the therapist by name, he denied any relationship with her and behaved as if intersubjectivity itself was deeply threatening. Whether this reaction again was due to a history of interpersonal trauma or metacognition deficit, the therapist started working on this element by noticing the simplest of dynamics occurring between them, stating, “You’re not sure what to make of me.” She kept in mind that an open stance is not always welcomed (22) and considered that the roles he wished her to play may have been based on the roles that others had in the past. Early during the therapy, for instance, she felt positioned as an authority figure who should control him and tell him what decisions to make. The therapist worked to further explore Geert’s wishes for her to act in the ways most familiar to him, and with time, she became a nonjudgmental observer who was curious about him.

In the fifth month, a new role for the therapist emerged as Geert considered the possibility that she thought of him outside of the sessions and that perhaps she was someone who valued him. This idea brought on feelings of fear, and Geert responded with opposition, caution, and what had been uncharacteristic interpersonal processes. For example, in one session, Geert yelled at her for being late, stating, “You are not reliable!” In the next session, he wrote the therapist a poem about a pretty flower. Each time the therapist, although caught off guard, had to remain open and nondefensive in order to best explore his reactions to her and consider what role she might be playing in the course of his life. After dreaming about him crawling around in a field, she acknowledged fears of patronizing and rejecting him, as others had done. On the other hand, she felt internal pressures to correct this seemingly inevitable interpersonal dynamic that had emerged, as therapy would soon end because the therapist was relocating. She allowed herself to be vulnerable in Geert’s presence and offered self-disclosure about how he had affected her life. This disclosure helped to normalize the interpersonal process that occurred over the course of meetings; namely, that two human beings had made a connection and related to one another. It also worked to stimulate him to think about his own internal reactions to the conversations he had with the therapist.

In the final session, Geert expressed a wish for the therapist to reject him like his mother had, elaborating it would be more familiar and less confusing. He then shared feelings of relief that his relationship with the therapist had turned out to be different. As such, he no longer found thinking about himself within the context of another to be bizarre or threatening. Overall, reflection of these interpersonal processes stimulated Geert to think about how the different ideas he holds of himself and others based on the past might affect his behaviors and interactions in the present.

Element 6: reflection on progress within the session.

The sixth element of MERIT requires an inquiry during each session regarding whether the client thinks the session has helped. Standard questions include “Has this been helpful today?” and “Did this go as you expected, and if so, was that good or bad?” The goal of such questions is not merely to assess progress but to make the overall course of a session, or group of sessions, a subject for reflection.

For Geert, just as thinking about the interpersonal processes had been a foreign activity, so had reflecting on the progress within the sessions. When asked about how a session had progressed, he was puzzled and often turned the question back to the therapist. She used simple and direct questions to better understand what had happened in his mind during the session: “Is this conversation what you expected?” and “Do you wish you had not come in today?”

With time, and as Geert started to see himself as an active agent, he started to state whether the sessions met or did not meet his expectations. In response, the therapist took time to understand why he thought that happened or why it did not. For example, he explained that a session went as expected since he had thought about what he wanted to say in advance, and the therapist responded in a manner he anticipated. By the fourth month, he noted some specific things that were accomplished during sessions, including feeling listened to by the therapist, having a space and time that was his own, and feeling accepted as a person with potentially shameful secrets.

Element 7: stimulating self-reflectivity and awareness of the other’s mind.

This element of MERIT calls for therapists to offer interventions that stimulate clients to engage in increasingly complex acts of self-reflection and reflection about others (13). Essential here is that the intervention stimulates clients to engage in forming thoughts about themselves and others at the level they are capable of, as assessed with the MAS-A. At the beginning of treatment, Geert was able to recognize that he had his own thoughts, but he struggled to identify, differentiate, or understand the processes that existed within his own mind.

Early interventions were offered to assist him in noticing that he experienced different cognitive operations, and then later, that he had a wide range of complex emotional states. For example, instead of talking about the devil, the therapist offered Geert reflections that directed him to differentiate between mental activities: “You have thoughts about the devil” and “You imagine how your life would be different.” As therapy progressed, Geert started to notice a difference between having a memory and planning for the future, and this process was further supported with reflections geared to emphasize these differentiations, such as, “You are having a memory of when you were 10 years old” and “You planned what you wanted to say in session today.”

By the fourth month, Geert started to piece together previously fragmented narrative episodes, which were now embedded with a more nuanced sense of his emotions. The therapist then used interventions to encourage Geert to focus on these emotions, such as, “When you think about your grandfather, you have a strong emotion.” Reflections were purposeful in nature and meant to stimulate Geert’s thinking about how he is a person with cognitive and emotional processes that exist in both the past and the present moment: “At the end of the session, you talk about something that makes you mad to prevent you from feeling sad”; and “You’re disappointed in me for having to reschedule.” As he started to express anger and frustration in a more nuanced manner, however, he quickly returned to delusional thoughts and lower levels of metacognition. This regression made for an increasingly difficult task and required patience by the therapist. Geert’s history of prolonged suffering and interpersonal abuse left him with intense pain that often could be tolerated only for short periods. His process could not be hurried. At times, the therapist offered interventions that were too complex; yet, as she became more sensitive to his profound levels of confusion and more willing to “sit with” his pain, she was able to offer interventions consonant with his current capacity and wait for him to work toward improved understanding of his own emotional states.

By the sixth month, he began to fully accept that his ideas were subjective and fallible, and shortly after, he reflected about he how had wishes that were at odds with reality. As he became consistently able to perform this mental activity, the therapist’s interventions became even more complex and involved interpretations about how differing aspects of his life might fit together. For instance, the therapist sought to stimulate thought about how thoughts and feelings are closely connected by stating, “You tend to wrap up our conversations with something that brings about feelings of anger. Did you notice that? Did you do that on purpose?” This intervention prompted Geert to reflect on feelings of anger in the present moment, and furthermore, how such emotion might affect other aspects of his life. He responded, “My anger keeps me comfortable at night. I want to let go and not hold onto to it, but without anger, I don’t know who I am.” Of note, there were many sessions in which previous gains seemed to be lost and Geert again functioned at a lower metacognitive level. In response, the therapist returned to offering interventions that better suited his level of metacognitive activity at that time.

In parallel with the work on self-reflectivity, interventions consonant with his current capacity were provided to stimulate his awareness of the mind of the other. The therapist often brought Geert’s attention to the present moment and to the minds of others about whom he spoke in various narratives: “As you sit here with me, what thoughts do you think go through my mind?” and “What do you imagine your grandfather was thinking in that moment?” These reflections were used to stimulate thought about how he perceives himself in particular moments of interpersonal contact and how he perceives others as they interact with him.

In the last session, Geert shared a complex account of his life that included integrated representations of himself and others. He linked together past and present events and considered how his interactions with the therapist might be affected by his previous interactions with others.

For example, he reflected on wishes not to say goodbye to the therapist, fears of anticipated rejection based on experiences with his mother, and temptations to perpetuate this interpersonal dynamic.

Element 8: stimulating mastery.

The final element of MERIT calls for the stimulation of mastery, or the ability to use knowledge about oneself and others to respond to psychological problems and challenges in daily life. At the beginning of therapy, Geert acknowledged that he experienced deep distress, yet he was unable to plausibly represent these concerns in his own mind and attributed his suffering to persecutors and outside forces. He essentially had no idea how he, as a unique being, could manage his own distress. At this point, the intervention was to explore Geert’s discomfort no matter how unusual, develop a shared sense of his pain, and establish a point of agreement about a plausible psychological problem.

In thinking about his tendencies to talk about the devil and considering past moments of acute distress, the therapist was better able to see delusional thoughts and lower levels of metacognition as protective. Consistent with observations in previous work (24), the therapist noticed that as potential vulnerability and interpersonal relatedness approached, psychotic content emerged. For instance, after a brief moment of eye contact between Geert and the therapist, it was noted that he reverted to thoughts about how the devil was instructing the psychiatrists to isolate him. These ideas prevented him from feeling vulnerable when in the presence of another. They also allowed him to view himself as someone with no control, rather than see himself as a human being who might find flaws and past upsets unbearable. Attending to his ideas by assuming a non-hierarchical stance and focusing on this consistent pattern over time allowed for an initial discussion of a potential psychological problem.

As narrative episodes were elicited about times when he felt disconnected from others, Geert began to think more about his fears of being known and rejected and how he responded to those fears. He also considered how these fears were driven by feelings of disappointment and guilt. To stimulate reflections about mastery, the therapist offered: “When you consider making a decision, your mind reminds you of times in which you felt disappointed by the choices you made.” These insights provoked Geert to think about larger understandings of the self, others, and the world, and he considered themes that connected narrative episodes over the course of his life. With time, he started to use this knowledge of himself to consider how he might respond in certain situations, which helped him to cope with anticipated distress when making new decisions and living independently in the future.

Outcome and Prognosis

Geert first came to psychotherapy with deeply limited metacognitive capacities. He was able to recognize that he had thoughts that were his own, but he struggled to know the different cognitive processes in his mind. He could not understand that others had autonomous thoughts and that others existed in a larger, complex social world outside of his own. He experienced himself as fragmented, had no coherent and plausible account of distress, and most significantly, did not see himself as an active agent in the world.

As the therapy was facilitated by each of the therapist’s use of the eight elements of MERIT, Geert has come to form integrated ideas about himself and others in the context of specific life events and to understand how to use this knowledge to respond to psychosocial challenges. He has recognized the fallibility of his thoughts and has developed new ideas about what prompts delusions and hallucinations. With increased ability to understand others’ thoughts and intentions, Geert has become less overwhelmed and fearful at being in the presence of another. Most significantly, he has identified a strong desire to connect and relate and an increased willingness to trust and be vulnerable.

Overall, he has developed a more robust account of life and perceives himself as an agent in the world who longs for connection, fears rejection, and regrets past decisions. Geert has formed a complex narrative that incorporates difficult cognitive, emotional, behavioral, and interpersonal processes, and he is able to make connections among these processes over the course of his life.

Symptomatically, Geert has had less severe positive and negative symptoms than he had prior to therapy. By the end of therapy, he no longer believed that his doctors were deliberately attempting to hurt him, and he did not experience life-interfering paranoid interpretations of stimuli. While he still hears the devil’s voice on occasion, he now believes these experiences are at odds with reality. Most dramatically, he can notice that interpersonal closeness stimulates delusional thought processes, which helps him to dismiss them. In terms of emotional withdrawal, he has made significant strides in forming deeper connections with friends and community members, and he now lives in his own home. Of note, his medication and dosages did not change during the course of psychotherapy.

With regard to prognosis, after the first few months of psychotherapy Geert no longer experienced exacerbations of his symptoms that mandated hospitalization, and his adherence to medication and improvements in both positive and negative symptoms bode well for the future. While more metacognitive gains remained possible in all the major areas assessed by the MAS-A, with continued participation in MERIT, he had regained substantial degrees of metacognitive capacity and could understand why he might want to do things and identify how he would like to manage associated challenges and risks. He thus appeared in a good position to be able to continue to recover and to avoid a life of prolonged dysfunction and isolation.

Conclusions

In this case report, the eight elements of MERIT were synergistically used to assist a man in the later phases of schizophrenia to achieve greater levels of self-reflectivity, awareness of others, decentration, and mastery. This client, however, faced some challenges unique to individuals with profound histories of sexual abuse. Specifically, more time was spent in the initial phases of psychotherapy to establish the trust and relatedness needed prior to exploring cognitive and internal processes. This process required considerable tolerance of high levels of discomfort on the part of the therapist given that Geert experienced overt emotional distress and fear when in the presence of another person. This work also called for greater self-reflection by the therapist as Geert positioned her in uncomfortable roles that likely served to perpetuate longstanding interpersonal dynamics. As such, the therapist often sought consultation and supervision to review her own internal processes, exploring her affective responses to Geert and her motivations behind interventions. Additionally, substantial time was spent talking about the interpersonal processes that occurred during and across sessions. Again, this work required not only great self-reflection but also thoughtful self-disclosure, genuineness, and vulnerability by the therapist. By considering her own responses and reactions, she was better able to understand Geert’s intersubjective processes, stimulate metacognition, and overall, support movements toward his recovery.

This case illustration has some limitations. More work is needed with formal assessments of metacognition and psychopathology over time in both case studies and controlled trials of this treatment to better measure isolated effects of these interventions. This case took place over seven months, and therefore, it is unclear how useful this treatment might be in settings that offer only shorter time commitments. Finally, future studies might continue to explore the interplay of the differing forms of metacognition assessed in this work.