# Promoting recovery from severe mental illness: Implications from research on metacognition and metacognitive reflection and insight therapy https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5862649/ [World J Psychiatry.](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5862649/#) 2018 Mar 22; 8(1): 1–11.  Published online 2018 Mar 22. doi: [10.5498/wjp.v8.i1.1](https://doi.org/10.5498%2Fwjp.v8.i1.1) PMCID: PMC5862649 PMID: [29568726](https://pubmed.ncbi.nlm.nih.gov/29568726) [Paul Henry Lysaker](https://pubmed.ncbi.nlm.nih.gov/?term=Lysaker%20PH%5BAuthor%5D), [Jay A Hamm](https://pubmed.ncbi.nlm.nih.gov/?term=Hamm%20JA%5BAuthor%5D), [Ilanit Hasson-Ohayon](https://pubmed.ncbi.nlm.nih.gov/?term=Hasson-Ohayon%20I%5BAuthor%5D), [Michelle L Pattison](https://pubmed.ncbi.nlm.nih.gov/?term=Pattison%20ML%5BAuthor%5D), and  [Bethany L Leonhardt](https://pubmed.ncbi.nlm.nih.gov/?term=Leonhardt%20BL%5BAuthor%5D) - Related [[Does Metacognitive therapies work]] --- # Metacognition #mindfulness [[Mindfulness]] - Thinking about Thinking ^6033e1 - "Having a cognition or thoughts about other cognitions" - Term have been applied to self-regulation. - The ability to monitor and correct reasoning and behavior - to reflect upon memory - An integrated model of metacognition** - metacognitive processes are what allow an integrated and cohesive sense of self and others to be available to an individual in a given moment. - "7. Lysaker PH, Klion R. New York: Routledge; 2017. Recovery, Meaning-Making, and Severe Mental Illness: A Comprehensive Guide to Metacognitive Reflection and Insight Therapy." Thinking about recovery from severe mental illness, the integrated model suggests metacognitive processes have at least 3 distinguished characteristics: **1. It's relational? How we view ourselves is influenced by relationships?** - "metacognitive acts occur and evolve intersubjectively. The ideas individuals have of themselves or others, whether elemental and complex, are formed with others in mind, others who may be either present or implicitly imagined, such that those ideas can be shared with and acknowledged by other people" **2. There are different metacognitive processes or focus. (1) Thinking about self (2) Of others (3) how self relates with social (3) how self respond to life's problem (agency)** 1. Second, metacognitive processes can be differentiated from one another according to their focus. As Semerari et al[[24](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5862649/#B24)] have described, there are four discernable objects or domains of metacognition which can be distinguished from one another. These include groups of metacognitive acts, which are focused on the self, others, one’s larger community and the use of knowledge about self and others to respond to life’s problems, or mastery **3. Metacognitive Processes are hierarchical. Each lower layer needs to be strong for the higher layer to be successful. i.e If thinking about self is inaccurate, perhaps it will affect thinking about others.** "Third, synthetic metacognitive processes are holistic in nature and involve a series of hierarchical steps. These steps are conceptualized, per domain, as a series of levels with each level incorporating something larger into what was incorporated into the step before it. For example, the fourth step of the metacognitive processes which are focused on the self adds and incorporates something new to what was incorporated in the third step allowing for a more complex sense of self to be available in the moment. A key implication of this is that for a given step to be operating successfully the step below it also has to be operating successfully. Consequently, once a step is not operating successfully then no higher step can operate in a fully successful manner given that those higher steps would necessarily be missing the information that was supposed to be provided by the more basic or lower step. This conceptual framework allows for individual differences in metacognitive capacity to be quantified and characterized as more or less functional on the basis of an identified level of metacognition which is not fully operational. Importantly, this is not to say that individuals with lesser metacognitive capacity have less experience of the self or others, but instead that their experience of self and others is less integrated or more fragmented. It is also not to imply a purely developmental model of metacognition, as individuals with lesser metacognitive abilities may have previously held these abilities but lost them for any number of different social, biological or psychological reasons" # How to measure metacognition? - Metacognition Assessment Scale (MAS) ## Research on metacognition in schizophrenia ^017494 - Research has addressed two broad questions (1)Are individuals with schizophrenia spectrum disorders more likely to experience disruptions in earlier or more basic aspects of metacognitive capacity; - They tend to experience disruptions in more basic levels of metacognitive capacity ([26](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5862649/#B26),[28](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5862649/#B28)[29](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5862649/#B29)[30](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5862649/#B30)) - and (2) when disruptions occur at more basic levels of metacognitive function, individuals are more likely to experience greater levels of impairment in current and future function. - It predicts generally poorer function, functional competence, poorer subjective sense of recovery, weaker therapeutic alliance in CBT, less ability to reject stigma, anhedonia, more sedentary life style, reduced awareness of negative changes in psychological and social function states, a lesser level of behaviour driven by internal reward. More likely to have vocational problems, more negative symptoms, and reduce intrinsic motivation. - "Concerning the relationship with function, disruptions observed in basic or more elemental levels of metacognition (referred to as more severe metacognitive deficits) have been found to predict generally poorer function[35]. This includes greater reductions in functional competence[36], reports of poorer subjective sense of recovery[37], a weaker therapeutic alliance in cognitive-behavior therapy[38], less reported ability to reject stigma[39], anhedonia in the absence of depression[40], a more sedentary life style[41], reduced awareness of negative changes in psychological and social function states[42] and lesser levels of behavior that is driven by internal rewards[43], all regardless of concurrent symptom severity. Individuals with schizophrenia spectrum disorders who experience disruptions in basic metacognitive function have also been found to be more likely to have future problems with vocational function[44], more likely to develop negative symptoms[45-47], and to experience reduced intrinsic motivation[48], regardless of baseline assessments of these phenomena." # So, how to treat it? **Help individual to form a more integrated sense of self and others (metacognition) would promote recovery** "The core assumption was individuals with a more fragmented sense of self and others would struggle to make sense of psychiatric and social challenges and thus struggle to move toward recovery. Put another way, a treatment enabling the processes which allow individuals to form a more integrated sense of self and others (i.e. metacognition) would promote recovery." # MERIT (Metacognitive Reflection and Insight Therapy) Principles: - recovery from serious mental illness is expected, regardless of the severity of the mental health condition - patients must be active agents who direct their own recovery during all phases of illness and that this requires the rejection of stigma - a non-hierarchical therapist-patient relationship in which the therapist’s role is best understood as one of a co-participant or consultant - not intended as a replacement for other treatments but can be offered both on its own or in combination with other rehabilitative practices depending on unique patient needs and clinic resources In MERIT, eight elements should be present in any given session > [! Simplified explanation] > There are eight different things that therapists talk about with their patients. These things can be divided into three groups. > > The first group is about the patient's experiences and needs right now. It includes discussing what the patient wants and needs (their agenda), how the patient sees the therapist's thoughts and feelings about them and their needs, and talking about specific moments from their life that show what they've been through. These discussions help the patient understand the psychological challenges they face. > > The second group is about how the therapy is going. It involves talking about the relationship between the patient and the therapist, how the patient sees themselves and other people, and discussing any changes or progress they've noticed in their thoughts and bodies. > > The last two things are important overall ideas that are discussed. One is about reflecting on oneself (thinking about who they are) and others (how they see other people), and the other is about feeling like they have control or understanding of things (mastery). The level at which these ideas are talked about depends on the patient's ability to understand and think about themselves in this way. > > So, therapists talk about these different things based on what the patient needs and what they can understand at that moment. Class 1 - Content Elements 1. The patient's agenda, wishes and needs in the moment 2. Patient's experience of the therapist's thoughts and feelings about the patient and his or her own agenda 3. patient's experience of life is revealed within specific and minimally abstract personal narrative episodes 4. psychological challenges which emerge from the first three content elements Class 2 - Process Elements 1. Discussion of the therapeutic relationship in which the patient is thinking about their sense of themselves and others 2. discussion of progress, including resultant changes in their minds and bodies Class 3 - Superordinate Elements 1. Reflect about self and others 2. Mastery to be stimulated at a level consonant with patient's metacognitive ability at the moment.