Hostname: page-component-55f67697df-px5tt Total loading time: 0 Render date: 2025-05-09T09:12:34.289Z Has data issue: false hasContentIssue false
  • English
  • Français

Metacognitive reflection and insight therapy (MERIT) for patients with schizophrenia

Published online by Cambridge University Press:  25 April 2018

S. de Jong Open the ORCID record for S. de Jong [Opens in a new window] ,
R. J. M. van Donkersgoed ,
M. E. Timmerman ,
M. aan het Rot ,
L. Wunderink ,
J. Arends ,
M. van Der Gaag ,
A. Aleman ,
P. H. Lysaker  and
G. H. M. Pijnenborg
S. de Jong*
Affiliation:
GGZ Noord-Drenthe, Department of Psychotic Disorders, Dennenweg 9, 9404 LA Assen, the Netherlands Department of Clinical Psychology, University of Amsterdam, Nieuwe Achtergracht 129-B 1018 WT Amsterdam, the Netherlands Department of Clinical Psychology and Experimental Psychopathology, Faculty of Behavioral and Social Sciences, University of Groningen, Grote Kruisstraat 2/1, 9712 TS Groningen, the Netherlands
R. J. M. van Donkersgoed
Affiliation:
Department of Clinical Psychology and Experimental Psychopathology, Faculty of Behavioral and Social Sciences, University of Groningen, Grote Kruisstraat 2/1, 9712 TS Groningen, the Netherlands Parnassia Dijk en Duin, Westzijde 120 1505 GB Zaandamthe Netherlands
M. E. Timmerman
Affiliation:
Department of Clinical Psychology and Experimental Psychopathology, Faculty of Behavioral and Social Sciences, University of Groningen, Grote Kruisstraat 2/1, 9712 TS Groningen, the Netherlands
M. aan het Rot
Affiliation:
Department of Clinical Psychology and Experimental Psychopathology, Faculty of Behavioral and Social Sciences, University of Groningen, Grote Kruisstraat 2/1, 9712 TS Groningen, the Netherlands
L. Wunderink
Affiliation:
GGZ Friesland, PO Box 932 8901 BS Leeuwarden, the Netherlands
J. Arends
Affiliation:
GGZ Noord-Drenthe, Department of Psychotic Disorders, Dennenweg 9, 9404 LA Assen, the Netherlands
M. van Der Gaag
Affiliation:
Parnassia Psychiatric Institute, Zoutkeetsingel 40 2512 HN Den Haag, the Netherlands Department of Clinical Psychology, VU University and Amsterdam Public Mental Health Research Institute, van der Boechorststraat 1, 1081 BT Amsterdam, The Netherlands
A. Aleman
Affiliation:
Department of Clinical Psychology and Experimental Psychopathology, Faculty of Behavioral and Social Sciences, University of Groningen, Grote Kruisstraat 2/1, 9712 TS Groningen, the Netherlands Department of Neuroscience, University of Groningen, University Medical Center Groningen, Antonius Deusinglaan 2, 9713 AW Groningen, the Netherlands
P. H. Lysaker
Affiliation:
Roudeboush VA Medical Center, 1481 West 10th Street, Indianapolis, IN 46202, USA Indiana University School of Medicine, 340 West 10th Street Suite 6200, Indianapolis, IN 46202, USA
G. H. M. Pijnenborg
Affiliation:
GGZ Noord-Drenthe, Department of Psychotic Disorders, Dennenweg 9, 9404 LA Assen, the Netherlands Department of Clinical Psychology and Experimental Psychopathology, Faculty of Behavioral and Social Sciences, University of Groningen, Grote Kruisstraat 2/1, 9712 TS Groningen, the Netherlands
*
Author for correspondence: S. de Jong, E-mail: [email protected]
Get access Rights & Permissions [Opens in a new window]

Abstract

Background

Impaired metacognition is associated with difficulties in the daily functioning of people with psychosis. Metacognition can be divided into four domains: Self-Reflection, Understanding the Other's Mind, Decentration, and Mastery. This study investigated whether Metacognitive Reflection and Insight Therapy (MERIT) can be used to improve metacognition.

Methods

This study is a randomized controlled trial. Patients in the active condition (n = 35) received forty MERIT sessions, the control group (n = 35) received treatment as usual. Multilevel intention-to-treat and completers analyses were performed for metacognition and secondary outcomes (psychotic symptomatology, cognitive insight, Theory of Mind, empathy, depression, self-stigma, quality of life, social functioning, and work readiness).

Results

Eighteen out of 35 participants finished treatment, half the drop-out stemmed from therapist attrition (N = 5) or before the first session (N = 4). Intention-to-treat analysis demonstrated that in both groups metacognition improved between pre- and post-measurements, with no significant differences between the groups. Patients who received MERIT continued to improve, while the control group returned to baseline, leading to significant differences at follow-up. Completers analysis (18/35) showed improvements on the Metacognition Assessment Scale (MAS-A) scales Self Reflectivity and metacognitive Mastery at follow-up. No effects were found on secondary outcomes.

Conclusions

On average, participants in the MERIT group were, based on MAS-A scores, at follow-up more likely to recognize their thoughts as changeable rather than as facts. MERIT might be useful for patients whose self-reflection is too limited to benefit from other therapies. Given how no changes were found in secondary measures, further research is needed. Limitations and suggestions for future research are discussed.

Keywords

Mentalizingmetacognitionpsychosispsychosocial interventionpsychotherapyrandomized controlled trialschizophreniatheory of mind
Type
Original Articles
Information
Psychological Medicine , Volume 49 , Issue 2 , January 2019 , pp. 303 - 313
Copyright
Copyright © Cambridge University Press 2018 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Article purchase

Temporarily unavailable

Footnotes

*

These authors contributed equally to the study and manuscript

References

aan het Rot, M and Hogenelst, K (2014) The influence of affective empathy and autism spectrum traits on empathic accuracy. PLoS ONE 9, 1–7.Google Scholar
Bargenquast, R and Schweitzer, RD (2014) Enhancing sense of recovery and self-reflectivity in people with schizophrenia: a pilot study of metacognitive narrative psychotherapy. Psychology and Psychotherapy: Theory, Research and Practice 87, 338–356.Google Scholar
Bargenquast, R, Schweitzer, RD and Drake, S (2015) Reawakening reflective capacity in the psychotherapy of schizophrenia: a case study. Journal of Clinical Psychology 71, 136–145.Google Scholar
Baron-Cohen, S, et al. (1999) Recognition of faux pas by normally developing children and children with Asperger syndrome or high-functioning autism. Journal of Autism and Developmental Disorders 29, 407–418.Google Scholar
Bateman, A, Fonagy, P and Allen, JG (2009) Theory and practice of mentalization-based therapy. In Gabbard, GO (ed). Textbook of Psychotherapeutic Treatments. Arlington, VA: American Psychiatric Publishing, 757–780.Google Scholar
Beck, AT, et al. (2004) A new instrument for measuring insight: the Beck Cognitive Insight Scale. Schizophrenia Research 68, 319–329.Google Scholar
Boyd Ritsher, J, Otilingam, PG and Grajales, M (2003) Internalized stigma of mental illness: psychometric properties of a new measure. Psychiatry Research 121, 31–49.Google Scholar
Buck, KD and George, SE (2016) Metacognitive reflective and insight therapy for a person who gained maximal levels of metacognitive capacity and was able to terminate therapy. Journal of Contemporary Psychotherapy 46, 187–195.Google Scholar
Buck, KD and Lysaker, PH (2009) Addressing metacognitive capacity in the psychotherapy for schizophrenia: a case study. Clinical Case Studies 8, 463–472.Google Scholar
Charlton, C, et al. (2017) MLwiN. Centre for Multilevel Modelling, University of Bristol: Bristol.Google Scholar
Choi-Kain, LW and Gunderson, JG (2008) Mentalization: ontogeny, assessment, and application in the treatment of borderline personality disorder. American Journal of Psychiatry 165, 1127–1135.Google Scholar
Davis, LW, Eicher, AC and Lysaker, PH (2011) Metacognition as a predictor of therapeutic alliance over 26 weeks of psychotherapy in schizophrenia. Schizophrenia Research 129, 85–90.Google Scholar
Davis, MH (1983) Measuring individual differences in empathy: evidence for a multidimensional approach. Journal of Personality and Social Psychology 44, 113–126.Google Scholar
de Jong, S, et al. (2016 a) Practical implications of metacognitively oriented psychotherapy in psychosis. Journal of Nervous and Mental Disease 204, 713–716.Google Scholar
de Jong, S, et al. (2016 b) Metacognitive reflection and insight therapy (MERIT) with a patient with severe symptoms of disorganization. Journal of Clinical Psychology 72, 164–174.Google Scholar
Dimaggio, G, et al. (2008) Know yourself and you shall know the other… to a certain extent: multiple paths of influence of self-reflection on mindreading. Consciousness and Cognition 17, 778–789.Google Scholar
Dimaggio, G, et al. (2007) Psychotherapy of Personality Disorders. London: Routledge.Google Scholar
Dubreucq, J, Delorme, C and Roure, R (2016) Metacognitive therapy focused on psychosocial function in psychosis. Journal of Contemporary Psychotherapy 46, 197–206.Google Scholar
Fonagy, P, Gergely, G and Jurist, EL (2002) Affect Regulation, Mentalization and the Development of the Self. New York: Other Press.Google Scholar
Frith, CD (1992) The Cognitive Neuropsychology of Schizophrenia. Hove: Lawrence Erlbaum Associates Ltd.Google Scholar
Gould, RA, et al. (2001) Cognitive therapy for psychosis in schizophrenia: an effect size analysis. Schizophrenia Research 48, 335–342.Google Scholar
Gross, JJ and John, OP (1995) Facets of emotional expressivity: three self-report factors and their correlates. Personality and Individual Differences 19, 555–568.Google Scholar
Hamm, JA and Firmin, RL (2016) Disorganization and individual psychotherapy for schizophrenia: a case report of metacognitive reflection and insight therapy. Journal of Contemporary Psychotherapy 46, 227–234.Google Scholar
Hamm, J, et al. (2012) Metacognition and social cognition in schizophrenia: stability and relationship to concurrent and prospective symptom assessments. Journal of Clinical Psychology 68, 1303–1312.Google Scholar
Haro, JM, et al. (2003) The clinical global impression-schizophrenia scale: a simple instrument to measure the diversity of symptoms present in schizophrenia. Acta Psychiatrica Scandinavica. Supplementum 107, 16–23.Google Scholar
Hasson-Ohayon, I, Kravetz, S and Lysaker, PH (2017) The special challenges of psychotherapy with persons with psychosis: intersubjective metacognitive model of agreement and shared meaning. Clinical Psychology and Psychotherapy 24, 428–440.Google Scholar
Hillis, JD, et al. (2015) Metacognitive reflective and insight therapy for people in early phase of a schizophrenia spectrum disorder. Journal of Clinical Psychology 71, 125–135.Google Scholar
Ickes, W (1997) Empathic Accuracy. New York: Guildford Press.Google Scholar
Kay, SR, Fiszbein, a and Opler, La (1987) The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophrenia Bulletin 13, 261–276.Google Scholar
Kazdin, AE (2010) Research Design in Clinical Psychology, 4th edn. Boston: Allyn & Bacon.Google Scholar
Kukla, M, Lysaker, PH and Salyers, MP (2013). Do persons with schizophrenia who have better metacognitive capacity also have a stronger subjective experience of recovery? Psychiatry Research 209, 381–385.Google Scholar
Ladegaard, N, et al. (2016) The course of social cognitive and metacognitive ability in depression: deficit are only partially normalized after full remission of first episode major depression. British Journal of Clinical Psychology 55, 269–286.Google Scholar
Lee, J, et al. (2011) Schizophrenia patients are impaired in empathic accuracy. Psychological Medicine 41, 2297–2304.Google Scholar
Leonhardt, BL, et al. (2016 a) Targeting insight in first episode psychosis: a case study of metacognitive reflection insight therapy (MERIT). Journal of Contemporary Psychotherapy 46, 207–216.Google Scholar
Leonhardt, BL, et al. (2016 b) Emergence of psychotic content in psychotherapy: an exploratory qualitative analysis of content, process, and therapist variables in a single case study. Psychotherapy Research 3307, 1–17.Google Scholar
Lysaker, PH, Buck, KD and Ringer, J (2007) The recovery of metacognitive capacity in schizophrenia across 32 months of individual psychotherapy: a case study. Psychotherapy Research 17, 713–720.Google Scholar
Lysaker, PH, et al. (2009) Lack of awareness of illness in schizophrenia: conceptualizations, correlates and treatment approaches. Expert Review of Neurotherapeutics 9, 1035–1043.Google Scholar
Lysaker, PH, et al. (2005 a) Metacognition amidst narratives of self and illness in schizophrenia: associations with neurocognition, symptoms, insight and quality of life. Acta Psychiatrica Scandinavica 112, 64–71.Google Scholar
Lysaker, PH, et al. (2005 b) Changes in narrative structure and content in schizophrenia in long term individual psychotherapy: a single case study. Clinical Psychology & Psychotherapy 12, 406–416.Google Scholar
Lysaker, PH and Dimaggio, G (2014) Metacognitive capacities for reflection in schizophrenia: implications for developing treatments. Schizophrenia Bulletin 40, 487–491.Google Scholar
Lysaker, PH, et al. (2010 a) Metacognition and schizophrenia: the capacity for self-reflectivity as a predictor for prospective assessments of work performance over six months. Schizophrenia Research 122, 124–130.Google Scholar
Lysaker, PH, et al. (2011 a) Metacognition in schizophrenia: the relationship of mastery to coping, insight, self-esteem, social anxiety, and various facets of neurocognition. The British Journal of Clinical Psychology/the British Psychological Society 50, 412–424.Google Scholar
Lysaker, PH, et al. (2011 b) Metacognition and social function in schizophrenia: associations of mastery with functional skills competence. Schizophrenia Research 131, 214–218.Google Scholar
Lysaker, PH, et al. (2011 c) Metacognition in schizophrenia: correlates and stability of deficits in theory of mind and self-reflectivity. Psychiatry Research 190, 18–22.Google Scholar
Lysaker, PH, et al. (2011 d) Addressing metacognitive capacity for self reflection in the psychotherapy for schizophrenia: a conceptual model of the key tasks and processes. Psychology and Psychotherapy 84, 58–69.Google Scholar
Lysaker, PH, et al. (2010 b) Metacognition as a mediator of the effects of impairments in neurocognition on social function in schizophrenia spectrum disorders. Acta Psychiatrica Scandinavica 122, 405–413.Google Scholar
Lysaker, PH, et al. (2014) Deficits in metacognitive capacity distinguish patients with schizophrenia from those with prolonged medical adversity. Journal of Psychiatric Research, 55, 126–132.Google Scholar
Lysaker, PH, et al. (2013) Depression and insight in schizophrenia: comparisons of levels of deficits in social cognition and metacognition and internalized stigma across three profiles. Schizophrenia Research 148, 18–23.Google Scholar
Macbeth, A, et al. (2014) Metacognition, symptoms and premorbid functioning in a first episode psychosis sample. Comprehensive Psychiatry 55, 268–273.Google Scholar
McGurk, SR and Mueser, KT (2006) Cognitive and clinical predictors of work outcomes in clients with schizophrenia receiving supported employment services: 4-year follow-up. Administration and Policy in Mental Health 33, 598–606.Google Scholar
Nasrallah, H, Morosini, P and Gagnon, DD (2008) Reliability, validity and ability to detect change of the personal and social performance scale in patients with stable schizophrenia. Psychiatry Research 161, 213–224.Google Scholar
Nicolò, G, et al. (2012) Associations of metacognition with symptoms, insight, and neurocognition in clinically stable outpatients with schizophrenia. Journal of Nervous and Mental Disease 200, 644–647.Google Scholar
Potkin, S, et al. (2012) PRM30 evaluating readiness for work in patients with schizophrenia: “The Readiness for Work Questionnaire” (WoRQ). Value in Health 15, A650.Google Scholar
Priebe, S, et al. (1999) Application and results of the Manchester short assessment of quality of life (Mansa). International Journal of Social Psychiatry 45, 7–12.Google Scholar
Reitan, RM and Wolfson, D (1985) The Halstead-Reitan Neuropsychological Test Battery: Therapy and Clinical Interpretation. Tucson: Neuropsychological Press.Google Scholar
Reniers, RLEP, et al. (2011) The QCAE: a questionnaire of cognitive and affective empathy. Journal of Personality Assessment 93, 84–95.Google Scholar
Riggs, SE, et al. (2012) Assessment of cognitive insight: a qualitative review. Schizophrenia Bulletin 38, 338–350.Google Scholar
Rush, JA, et al. (2003) The 16-item quick inventory of depressive symptomatology (QIDS), clinician rating (QIDS-C), and self-report (QIDS-SR): a psychometric evaluation in patients with chronic major depression. Depression 54, 573–583.Google Scholar
Schmand, BA, et al. (1991) De Nederlandse Leestest voor Volwassenen: een maat voor het premorbide intelligentieniveau. The Dutch aduld reading test: a measure of premorbid intelligence. Tijdschrift voor Gerontologie en Geriatrie 22, 15–19.Google Scholar
Semerari, A, et al. (2003) How to evaluate metacognitive functioning in psychotherapy? The metacognition assessment scale and its applications. Clinical Psychology & Psychotherapy 10, 238–261.Google Scholar
Sheehan, DV, et al. (1998) The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry 59, 22–33.Google Scholar
Snijders, TAB and Bosker, RJ (2000) Multilevel Analysis: An Introduction to Basic and Advanced Multilevel Modeling Second Edition. London: Sage.Google Scholar
Tombaugh, TN (2004) Trail making test A and B: normative data stratified by age and education. Archives of Clinical Neuropsychology: the Official Journal of the National Academy of Neuropsychologists 19, 203–214.Google Scholar
van der Meer, L, et al. (2010) Self-reflection and the brain: a theoretical review and meta-analysis of neuroimaging studies with implications for schizophrenia. Neuroscience and Biobehavioral Reviews 34, 935–946.Google Scholar
van Donkersgoed, RJM, et al. (2014) A manual-based individual therapy to improve metacognition in schizophrenia: protocol of a multi-center RCT. BMC Psychiatry 14, 27.Google Scholar
van Donkersgoed, RJM, de Jong, S and Pijnenborg, GHM (2016) Metacognitive reflection and insight therapy (MERIT) with a patient with persistent negative symptoms. Journal of Contemporary Psychotherapy 46, 245–253.Google Scholar
van Veluw, SJ and Chance, Sa (2014) Differentiating between self and others: an ALE meta-analysis of fMRI studies of self-recognition and theory of mind. Brain Imaging and Behavior 8, 24–38.Google Scholar
Wechsler, D (1995) Manual for the Wechsler Adult Intelligence Scale. Oxford: Psychological Corp.Google Scholar
Wykes, T, et al. (2008) Cognitive behavior therapy for schizophrenia: effect sizes, clinical models, and methodological rigor. Schizophrenia Bulletin 34, 523–537.Google Scholar
Supplementary material: File

de Jong et al. supplementary material

Tables S4-S5

Download de Jong et al. supplementary material(File)
File 20 KB