Recovery in First-Episode Psychosis: A Case Study of Metacognitive Reflection and Insight Therapy (MERIT)

Despite early pessimism about the chronicity and course of schizophrenia spectrum disorders in psychiatry, there has been a shift in discussion in research, treatment, and policy suggesting that recovery from severe mental illness is possible. Various factors have contributed to this shift, including long-term outcomes studies that show a heterogeneous course for those with schizophrenia spectrum disorders (1), as well as a shift in the conceptualization of recovery in serious mental illness. Due to a grassroots movement of activists and scholars embracing a broadened view of recovery, recovery now includes a process of regaining autonomy over one’s life and a return to meaningful life roles, even in the face of persisting symptoms or difficulties (2, 3). This aspect of recovery is called many things, including recovery as process and subjective recovery. Included in this definition of recovery is that individuals see themselves as more than a mental health patient, feel empowered to make decisions about their lives and health care, and can participate in aspects of their community that are meaningful to them (2).

This broadened view of recovery has several implications for interventions offered to individuals with schizophrenia spectrum disorders. In particular, with a recent emphasis on intervening early in the course of illness, or first-episode psychosis (FEP), a broadened view of recovery has implications for the types of interventions offered in FEP clinics. The literature to date has shown that early intervention in FEP is related to a range of improved outcomes (4), yet these outcomes are often more objectively defined, such as symptom remission, use of acute services, and level of functioning. While these outcomes are important, it remains unanswered how early intervention can assist individuals with FEP to attain subjective recovery.

One promising intervention that may assist in promoting recovery in FEP is metacognitive reflection and insight therapy (MERIT; 5). MERIT is an integrative psychotherapy that targets metacognition. Metacognition refers to a range of cognitive activities that allow one to form complex, flexible accounts of one’s own life, as well as of significant others, and to use this knowledge to respond to a range of psychosocial problems (6). Deficits in metacognition have been found to exist in schizophrenia spectrum disorders (7, 8), to be stable (9), and to be present across all phases of illness, including FEP (10). Promoting metacognition may assist persons in moving toward subjective recovery because it may be necessary to think in a sophisticated way about oneself to obtain this type of recovery. For example, thinking flexibly and coherently about oneself may allow one to see oneself as more than a mental health patient, to identify a range of passions and life roles that would make one’s life fulfilling, and to be able to respond flexibly to psychosocial distress.

There is some evidence to suggest that higher metacognition is related to an improved sense of subjective recovery in those with schizophrenia spectrum disorders (11), and offering interventions such as MERIT that specifically target metacognition may assist in promoting recovery. In fact, in a sample of individuals with prolonged psychosis, metacognitively oriented psychotherapy was found to assist in forming a coherent sense of self and to ultimately promote recovery (12). Additionally, case studies have been reported examining the use of MERIT as an intervention to target and promote insight in FEP (13, 14). The following case builds upon this work to illustrate the use of MERIT as an intervention promoting recovery in FEP.

Presenting Problem and Client Background

The client for this case will be referred to as Grohl. All identifying information has been altered to protect his confidentiality. Grohl is a single male in his early to mid-20s who was diagnosed as having schizophrenia two years prior to his engagement in therapy. He grew up as the eldest of three children in a middle-class family and reported no developmental concerns or delays. Grohl described himself as having many friends during his childhood and reported he was involved in extracurricular activities and performed well in school. Prior to his diagnosis of schizophrenia, he had no other mental health diagnoses or mental health treatment. He was a talented artist and was active in his high school’s art community. He and his parents noted a change after high school in which Grohl became less social and struggled academically in his college classes. Immediately after high school, Grohl relocated from living with his family of origin to living with his grandfather in a different city in the same state. He had limited contact with his family of origin during that time and began to experience a change in his level of psychosocial functioning: socially withdrawing, failing to keep jobs, and eventually dropping out of school. Grohl’s grandfather struggled with substance abuse during this time and was actively using substances while Grohl lived with him. Grohl and his parents reported that there were often verbal and physical fights as a result of Grohl’s grandfather’s substance use and overall this was a tumultuous time for Grohl. Grohl’s own substance use included occasional marijuana and alcohol in high school, and he reported drinking alcohol several times per week while living with his grandfather. He had legal charges related to an arrest for underage drinking.

During the onset of Grohl’s illness, he began to believe a range of persecutory delusions that often centered on his physical health, stating that others were poisoning him and noting strange physical sensations that he believed were a result of the poison he was administered. His grandfather took him to a behavioral health center where Grohl was diagnosed as having schizophrenia and an oral second-generation antipsychotic was prescribed, which he took intermittently. Grohl lived with his grandfather and occasionally sought medical assistance for physical sensations for one-and-a-half years before he visited emergency rooms in several states, attempting to convince hospital staff that he was being poisoned and requesting medical attention. Grohl would leave the emergency room before care could be administered. He was eventually detained by the police due to erratic behavior and was transferred to an inpatient hospital close to his parents’ residence. It was following this hospitalization that Grohl was linked to the early psychosis clinic. While on the inpatient unit, Grohl was involuntarily committed due to his refusal to take medications and his attempts to leave the unit against medical advice. He began receiving an injection of paliperidone palmitate. Grohl eventually moved to a supported living environment and attended an outpatient clinic, receiving case management and medication services for six months before agreeing to psychotherapy. He remained on a stable dose of his medications during the duration of the therapy presented below, and he received services from a multidisciplinary team, including case management and supported employment services. In addition, because of Grohl’s somatic complaints, he received care at several primary and specialty care clinics to evaluate his health. He received a diagnosis of gastroesophageal reflux disease and was treated for this condition. He received no other medical diagnoses.

When Grohl began therapy, he was primarily experiencing negative symptoms. He experienced thought blocking, prolonged response latency, anhedonia, and flat affect. He described that his mind was “empty” and noted that he spent much of his day lying in his bed. Grohl was unemployed at the time and saw his family once per week when his parents picked him up for a family Sunday dinner. He had no other social contact. He endorsed avolition, noting that despite being bored much of the time he was not motivated to engage in any behaviors that he used to find enjoyable, such as creating art, spending time in Internet forums, or spending time with his friends. Grohl was quiet, rarely made eye contact, and often came to his psychotherapy session appearing disheveled.

Case Conceptualization

Grohl’s deficits in metacognition were assessed with the Metacognition Assessment Scale-Abbreviated (MAS-A; 15), which is an adaptation of the original MAS (16) and includes four domains of metacognition: self-reflectivity, awareness of others, decentration, and mastery. Each part of the scale is hierarchical, with higher scores representing increased capacity to perform the complex mental tasks of each domain. Self-reflectivity refers to the ability to acknowledge and identify internal states and to ultimately form flexible understandings of oneself and one’s unique life events over time. Grohl initially had low self-reflectivity. Although he was able to distinguish a range of cognitive operations, he was unable to name a nuanced range of emotions or recognize that his thoughts were fallible, giving him a score of 3 out of 9 on the self-reflectivity scale. For example, Grohl remained convinced that he was being poisoned by an unnamed entity and remained adamant that he had holes in his head that were causing discomfort in his body. Awareness of others refers to the ability to consider other people’s internal states and to make guesses about their intentions. Grohl also scored low in this capacity. He recognized that others had their own internal states but was unable to name a range of emotions significant others in his life might experience and struggled to guess their intentions. He was evaluated at a 3 out of a possible score of 7 on this subscale of the MAS-A. Decentration refers to the ability to recognize that one is not the center of all activities and that other people have differing, valid opinions separate from one’s own. Grohl tended to view events as being connected to him, often believing that others wished him harm, and failed to consider that others in his life had lives outside of his. He scored 0 out of 3 on this scale. Finally, mastery refers to the ability to use knowledge about oneself to respond in increasingly complex ways to psychological problems. Grohl initially came to therapy without a clear psychological problem, often stating that something had gone wrong in his life but attributing that distress to the malicious, unnamed individuals who he believed were causing his physical sensations. Thus, his score on mastery was a 1.5 out of 9.0 because he did not meet the criteria of articulating a plausible psychological problem.

Course of Treatment

The therapy described below refers to an 18-month period of weekly individual psychotherapy utilizing MERIT. MERIT is an integrative psychotherapy with eight core elements incorporated into each session. These elements can be used along with a range of therapeutic approaches and offer therapists a method of building upon existing skills and conceptualizations and employing a flexible framework that centers on increasing the client’s metacognitive capacity (17). Each of these elements is briefly defined below, along with a description of how that element was addressed in Grohl’s psychotherapy.

Element 1: The Preeminent Role of the Client’s Agenda

This element refers to, first and foremost, establishing what the client wants from the session that day. Agendas are often not clearly articulated, and it is possible for clients to have multiple, and at times conflicting, agendas at once. For example, a client could wish that a therapist agree that he or she is a victim of a jealous neighbor or may want the therapist to view him or her as independent and capable. Attending to these agendas requires that therapists be curious about and attentive to the ways in which the client’s desires pull for a reaction in a session, whether it is to be viewed a certain way or for the therapist to take a certain action.

Initially, Grohl’s agenda appeared to be to convince the therapist that he did not have a mental illness and to get her to agree with his belief that others were causing his physical symptoms through attacks on him in his sleep. Grohl often was adversarial with his psychiatrist, asserting that he did not have schizophrenia and noting his anger at being forced to take medications he did not believe he needed. The therapist responded to these agendas with curiosity about Grohl’s physical symptoms and attempted to gather a timeline and narrative episodes surrounding the onset of these symptoms. When Grohl would directly ask the therapist to align with him against his psychiatrist by asking whether she agreed that he did not have schizophrenia but was the victim of a conspiracy, she responded by reflecting on the dynamics of Grohl’s agenda and with curiosity about what her agreement would mean to him. The therapist would then request more information about Grohl’s experience to better understand what he was experiencing. It seemed important to the therapist that she remain open to and curious about Grohl’s agenda rather than attempting to promote her own agenda (such as improving insight or adherence to treatment). The therapist’s openness seemed to allow Grohl to move at a pace with which he was comfortable, which ultimately seemed to promote trust and further exploration of Grohl’s life story. However, at times moving at Grohl’s pace was difficult, and often the treatment team would experience impatience or anxiety as Grohl continued to attempt to get body scans or other medical procedures to address his somatic experiences.

Element 2: Introduction of the Therapist’s Thoughts as Dialogue

This element refers to the therapist offering his or her own reflections and reactions throughout the session to promote dialogue. The therapist’s mental contents are fodder for reflection and not presented as fact or a more accurate view of reality but to encourage the client to react to the therapist’s reflections so the two can think together about them.

The therapist initially achieved this element with Grohl by stating her confusion about the claims he was asserting regarding his physical sensations. As Grohl provided more information and reflected upon the events surrounding the onset of these sensations, it occurred to the therapist that Grohl often experienced these strange sensations when he felt unsafe. He reported that the sensations began while living with his grandfather, who was unpredictable and often verbally and physically abusive to Grohl, including attacking him in his sleep. Since then, Grohl had moved into a supported living home with individuals with psychiatric needs in a neighborhood in the city that was known for being unsafe. Grohl often reported being most bothered by these physical symptoms when he was around others living in the home, and he reported that he did not experience these symptoms at his parents’ home. The therapist responded to Grohl by offering reflections such as “When you share these stories, it makes me wonder if you felt threatened,” and, “I have a thought that you felt unsafe staying with your grandfather.” The therapist would then invite Grohl to comment on her reflections.

Element 3: Eliciting Narrative Episodes

The third element of MERIT emphasizes the importance of eliciting narrative episodes to assist clients in developing a storied sense of their lives over time. This element was particularly important with Grohl and was challenging in the beginning due to his barren account of his life. Grohl described his life as being successful and positive until the physical sensations began, to which he attributed all his dissatisfaction with his current circumstances. The therapist elicited narratives by asking for more details about the onset of his physical symptoms and attempting to gather information about where he was living and with whom he was interacting. Eventually, she began to compile a timeline of Grohl’s life. He often responded to the therapist’s inquiries by stating that he could not remember his life. By revisiting the few narratives he could offer, Grohl eventually was able to provide more details to these narratives and slowly, narratives of other times arose. A richer picture of his life emerged, including his account of the abuse he endured while living with his grandfather, his sense of having failed at becoming an independent adult, his social discomfort in high school, and his remembering of his love and dedication to art. With this richer picture of his life, Grohl’s account of having experienced a perfect life prior to the onset of physical symptoms was challenged and evolved into a rich, storied sense of his unique life, including his challenges and triumphs. This richer version of Grohl’s life often caused him pain and discomfort, as he grappled with a sense of loss of dreams he previously had for himself and struggled with acceptance of painful interactions with significant others. Likewise, this process was difficult at times for the therapist as she watched Grohl struggle with painful aspects of his life and continued to encourage him to reflect and explore potentially distressing narratives. Despite the discomfort that often accompanied the increased reflectivity, Grohl appeared better able to make sense of his life. Exploring narratives seemed to allow Grohl to finally come to terms with experiencing psychiatric difficulties as well as to see himself as a full being and not only a psychiatric patient.

Element 4: The Psychological Problem

The fourth element refers to assisting clients in forming a plausible, mutually agreed upon psychological problem. The psychological problem often emerges from the understanding of the client’s agenda and narratives and may include a range of difficulties not restricted to a mental disorder. Examples of these difficulties could include struggling to connect with others in an adaptive manner or difficulty in understanding the intentions of others and thus navigating interactions.

Initially, Grohl struggled to form a plausible psychological problem and focused on implausible explanations for the distress he was experiencing. He often stated that others were poisoning him or performing operations on him while he was sleeping, leaving no trace of surgical scars when he woke. These expressions often left the therapist in a difficult position, because she could not join Grohl in these explanations of his difficulties. However, through exploration of the development of these physical sensations and the narratives he offered, Grohl began to articulate a psychological problem that something had gone wrong in his life and that he had gotten off track. He considered factors that could have influenced the course of his life, expanding these factors from his suspicions of others to include his decreased self-esteem caused by perceived failures, such as of losing jobs, dropping out of college, and new difficulties in connecting with others. Grohl’s understanding of his psychological problem continued to evolve as he discussed various narrative episodes in his life and considered what had changed. He began to acknowledge difficulties occurring earlier in his life and in particular reflected on the impact of his grandfather’s abuse. He described themes of feeling unsafe, struggling to perceive the intentions of others, and feeling left behind in life, as his peers and siblings established their autonomy in young adulthood in ways in which Grohl felt he should but was unable.

Element 5: Reflecting on Interpersonal Processes

This element requires attention to and reflection on the interpersonal dynamics occurring within the therapy sessions by both the therapist and client. This element was difficult with Grohl, who would struggle to describe his reactions to the therapist. He seemed initially unsure of the therapist and her intentions and would state that he was not sure what to talk about during the sessions. Grohl often noted surprise at having talked through the entire session.

Another significant interpersonal process in Grohl’s psychotherapy was seen in his attempts to convince his therapist that he did not have a mental illness and should not have to be in treatment. At times he would experience the therapist’s curiosity as challenging the legitimacy of what he was experiencing and would offer statements attempting to legitimize his experiences, such as “This isn’t all in my head” and “There is something seriously wrong with my body, and I’m afraid I’m going to die.” At times he perceived his therapist as being on his side and would attempt to recruit her help in procuring a body scan that would “prove” the damage he was sure was happening to his body. The therapist described her experience during these moments as feeling pulled in different directions by Grohl, and she would invite him to reflect on how he perceived her during these moments as well and to react to her reflections.

Element 6: Reflecting on the Process of Therapy Within and Across Sessions

In practicing element 6, the therapist invites feedback from the client on how the session has gone each time as well as to reflect on the therapy process as a whole. In MERIT, the process of therapy is viewed as an opportunity for reflection and dialogue about the connection between two individuals over time and how this connection can evolve. Initially, Grohl described that sessions went well but also noted his discomfort in knowing what to talk about. As he reflected on more of his life and developed a conceptualization of his psychological problem, Grohl would describe that he was thinking about his life differently as a result of therapy. He noted that these reflections were at times painful, particularly when describing memories of his earliest experiences of psychosis and traumatic interactions with his grandfather. The therapist would often observe a change in Grohl in the sessions following exploration of his relationship with his grandfather. Specifically, Grohl tended to describe his grandfather in an overwhelmingly positive manner in the sessions following his disclosure of painful moments with him. The therapist would note this change between sessions and explore with Grohl his ambivalence about his relationship with his grandfather and about discussing and reflecting on painful moments in his life.

Element 7: Stimulating Reflectivity of Self and Others

One of the hallmarks of MERIT is the stimulation of reflective activity at the appropriate level of metacognition. This stimulation requires the therapist to continuously assess clients’ current level of metacognitive capacity to reflect on the internal states of themselves and others. The therapist then offers interventions at that level or attempts to assist them to the next highest level through scaffolding. Offering interventions that are either too metacognitively complex or simple is viewed as ineffective as the client is being asked to reflect at a level that does not match his or her current capacity. Of note, metacognitive capacity is dynamic and changes between sessions and often even within sessions (18), so to effectively perform this element, therapists must frequently assess the client’s metacognitive capacity.

In this case, the therapist first needed to intervene to provide a scaffold for Grohl to express a range of nuanced emotions, as Grohl could describe a range of cognitive operations but could not identify how he was feeling in various narratives. The therapist performed this intervention by inviting Grohl to describe the circumstances around the beginning of his physical symptoms. This encouragement led him to describe narrative episodes that, while initially barren, gave some material for Grohl and the therapist to reflect upon. The therapist would stimulate self-reflectivity by asking Grohl to describe his reactions to events in these narratives and the various feelings within his body during those moments. The therapist would offer labels for emotions and at times would describe her own guesses about how she might feel if she were experiencing the narrative Grohl described, exploring how those guesses fit or did not fit for Grohl, fine-tuning his understanding of how he was feeling. During the exploration of these initial barren narratives, Grohl began offering narratives from earlier periods in his life, and more details emerged, particularly his complicated and traumatic interactions with his grandfather. As Grohl developed his ability to reflect on a range of emotions, the therapist also began to scaffold the fallibility of thoughts, assisting Grohl in exploring how his thoughts had changed over time. He was most able to do this when thinking about events in the past, and he struggled to recognize that his current thoughts were also fallible. To address this, the therapist would invite Grohl to reflect on his certainty within the moment and how that differed from times in the past when his thoughts had changed. Ultimately, as Grohl began reflecting on his life in more detail and began to integrate the circumstances of significant points of his life, he developed a more complex understanding of himself and the psychosocial events he had experienced.

When Grohl began to offer narrative episodes that included significant others in his life, the therapist targeted his ability to understand the internal states of other people. Grohl initially struggled to recognize a range of nuanced emotion in others. As he developed the capacity to describe his own nuanced emotional states, he began to consider the emotional states of others. When Grohl considered his family dynamics, the therapist would often stimulate reflectivity of others by asking Grohl how he thought his parents viewed or reacted to significant events. He began to articulate, and form guesses about how certain events, such as the onset of his illness, had affected others in his family. As Grohl considered the impact his relationship with his grandfather had upon him, he was receptive to interventions that invited him to reflect upon aspects of his grandfather’s life that may have influenced his grandfather’s behavior. Grohl began to think flexibly about an individual who had caused him much pain and developed some hypotheses about what may have influenced his grandfather’s behavior.

Element 8: Stimulating Psychological Mastery

The eighth and final element of MERIT requires the therapist to offer interventions to stimulate metacognitive mastery, or the use of knowledge of self and others to respond to psychological distress. Similar to stimulating reflectivity of self and others at the correct metacognitive level, mastery interventions also must be tailored to the metacognitive capacity of the client. Stimulation of mastery includes assisting clients to form a plausible psychological problem and then to develop increasingly complex ways to master the problem. Interventions become more complex as they include the knowledge gained in reflection about self and others to navigate difficulties in life.

For Grohl, the therapist first began to stimulate mastery by offering interventions to promote reflectivity about what his plausible psychological problem might be. As discussed in the fourth element, Grohl initially struggled to articulate a problem that was plausible, but through exploration of the onset of his physical problems, he was eventually able to describe that his life had gotten off track and to acknowledge his difficulty in assessing others’ intentions and interacting successfully. As Grohl became more reflective of significant moments in his past, he began to describe the fulfillment he found while creating art. He began to create again and engaged this part of himself, eventually even agreeing to do contracted pieces of art as he had in the past. Being paid to create caused Grohl great anxiety initially, as he wondered whether he would perform to his past abilities and feared he might disappoint those who were paying him. However, he was successful with his first few pieces, and this success improved his self-esteem and sense of agency over aspects of his life.

As Grohl began to gain self-confidence and continued to reflect on the change he noticed in his life’s trajectory, his explanation of his psychological problem again evolved. He began to describe narratives he had previously not mentioned and acknowledged experiencing psychotic symptoms, which he had formerly denied. What emerged was a more complex understanding of the unique life circumstances that had led him to experience a high level of stress and a sense of being lost. He reflected on his history of being anxious as a child and as a rebellious teenager, and he noted how he had often overcompensated for his insecurity by acting out while in high school. Grohl abandoned the narrative that he had previously stated, that all was perfect in his life prior to his physical sensations and described a childhood of uncertainty that included moments of strength and happiness. Describing the moments of happiness led him to conclude that it was important to connect more with his family of origin and with the passions he had, including art.

Clinical Outcomes

Significantly, Grohl appears to have made gains in his personal recovery. At the beginning of therapy, he was unemployed and isolated, and much of his focus (including interactions with his family) was on his physical experiences. Within two years of starting therapy, Grohl’s life looked considerably different. He has been employed for 18 months at one job and recently added a second job. He has reconnected with his family members and sees them several times every week. He has reestablished an old friendship and begun two new ones. He engages with his community by creating murals for the church he attends and taking other offers to generate art. Additionally, he lives independently in an apartment, has bought a car, has gotten a pet, and has other accomplishments that seem to illustrate a dynamic life. As Anthony (19) points out, the meaning of recovery for each individual is deeply personal, and thus Grohl’s own subjective sense of recovery is the best marker for whether or not he is in recovery from his severe mental illness. Grohl describes in therapy sessions that he has an improved quality of life, expressing that while he still feels anxious and unsure about taking chances on his future, he feels more fulfilled with his current life than he did two years ago. He articulates an improved sense of self-esteem and appears to experience himself as an agent, even making decisions about his mental health care and how and when he will engage in it. He seems to rely less on his parents to make decisions for him, although he considers their advice. Grohl is actively pursuing higher education opportunities and has been reflecting on what type of career he would like. He is planning to start college within the next year.

Thus, while this case has results similar to other case studies using MERIT for patients with FEP, such as an increase in insight and decrease in symptoms (14), Grohl’s case also illustrates the movement from being dominated by a mental health condition to living a more fulfilling and enriched life in recovery. While this case occurred within clinical practice and thus other contributing and confounding factors cannot be ruled out, it seems likely that the use of MERIT promoted Grohl’s recovery. We posit that MERIT promotes recovery for two reasons: first, each of its elements supports the core values of recovery, and second, metacognitive capacity may be necessary to achieve many of the subjective elements of recovery.

By starting with the first of these two assertions, that the eight elements of MERIT support the tenets of recovery, we see that elements 1, 4, 5, 6, 7, and 8 all position the client as an agent with an agenda, a mind for dialogue, and an active participant in care, thus encouraging self-direction. Element 1, or the preeminent role of the client’s agenda, places importance on understanding what the client wants in a given moment, creating a therapeutic environment with multiple pathways to recovery, tailored to what is important to the individual and allowing for self-direction. MERIT promotes an open stance, in which the therapist does not operate as an expert but rather as a consultant, serving as a guide to explore the content of one’s own mind. The MERIT therapist does not merely mirror the client, but in addition to providing reflections of the client’s mind, actively offers his or her own thoughts to discuss and react to within the therapy encounter (elements 2 and 5). MERIT also supports recovery through the therapist’s interest in the client’s story and life before and after illness, helping the client recapture a sense of self rather than just focusing on symptom relief or eradication of unhealthy thoughts and behaviors (element 3). Thus, all eight elements of MERIT support the core values of recovery.

Turning to the second assertion, MERIT may assist persons in the types of sense-making that are necessary to achieve subjective recovery. For example, having a storied sense of one’s life as having good moments as well as challenges aligns with the recovery tenets of seeing oneself as more than a mental health patient, feeling empowered to make decisions about one’s life, and ultimately recapturing a sense of self. By contrast, having significant metacognitive deficits may make achieving subjective elements of recovery difficult if one is struggling to identify one’s own hopes and dreams and to understand and respond to psychological challenges. Thus, it may be that by promoting metacognitive capacity through the eight elements of MERIT, therapists are able to assist clients in forming flexible, coherent understandings of themselves, others, and their unique challenges in life and begin to respond to them.

Significantly, Grohl made gains on each of the four metacognition subscales. Grohl began to describe and recognize a range of nuanced emotions; began to view his thoughts as fallible and thus changeable; believed that his expectations were not always reality; and began to integrate his thoughts, feelings, and behaviors when thinking about specific narrative episodes of his life. Thus, Grohl moved from a 3 to a 6.5 on self-reflectivity. He also began to see other people as having rich internal experiences and began to make guesses about their intentions using unique information about them, thus moving from a 3 to a 5 on awareness of others. Grohl initially scored a 0 on decentration, as he thought all others were somehow tied to a conspiracy against him. He developed a different view, however, and was able to see others as having their own lives separate from him, and he even began to consider that other people have valid but differing opinions from him, placing him at 1.5 on the scale. Finally, Grohl developed a plausible psychological problem and began to use behavioral strategies, such as engaging in artistic endeavors, to manage his distress, moving him from a 1.5 to a 5 on the mastery scale.

Although case studies provide in-depth examinations of an individual’s experience, they have limitations. The findings from this case study may not be generalizable to other individuals. More work is needed with individuals of differing demographic characteristics and phases of illness to assess the generalizability of these findings. Additionally, other factors external to Grohl’s psychotherapy may have had an impact on his ability to recover, including other services he received, such as medication management and supported employment services. Despite these limitations and given the larger body of literature and the findings of this case, MERIT appears to be a promising intervention that may help promote recovery for patients with FEP.