Metacognition (‘thinking about thinking’) and a Novel Treatment for People with Severe Mental Illness

Recently, there’s been a noticeable increase in interest in mental health services for people with a severe mental illness – schizophrenia, schizoaffective disorder, bipolar disorder, borderline personality disorder, post-traumatic stress disorder, and major depressive disorder are generally considered as a severe mental illness. Compared to people with a non-severe mental illness, those with a severe mental illness have been found to experience: higher rates of disability, morbidity and mortality; greater stigma and social isolation; poorer physical health, insight, and quality of life; and greater alcohol and substance misuse issues. These issues have resulted in large and ongoing personal, social and economic costs. With a shift in the view of severe mental illness – from a chronic, incapacitating, and worsening over the life course perspective – to the notion of recovery, it has become crucial to gain a better understanding of psychological factors that may affect the recovery of people with these diagnoses. Exploring the experiences of people with a severe mental illness who have observed improvements in their functioning has brought to surface recovery as being a journey of small steps, characterised by a growing sense of agency, participation in normative life processes (e.g., employment), and an empowering mental health system. Self-reports of people with a severe mental illness who participated in the Yale Longitudinal Study of Prolonged Psychiatric Disorder (this study focused on major affective disorder, schizophrenia, and schizoaffective disorder) revealed that those who experienced significant improvements in overall functioning all described, at different points during the course of their recovery, experiences involving the rediscovery and reconstruction of a sense of self. This is important because it suggests that the sense of self plays a key role in the understanding and treatment of severe mental illness, and addressing any disruptions to it may increase the chances of improving symptom severity, social functioning, course of recovery, and overall psychological well-being.

This has given rise to a new and promising area of research and clinical practice. Of particular interest is the construct known as metacognition. Metacognition is considered to be a psychological function involving thinking about thinking. One view more specifically defines metacognition as comprising four fundamental components:

1. Self-reflectivity: Ability to think about one’s own thoughts and emotions   2. Understanding the other’s mind: Ability to think about the thoughts and emotions of others   3. Decentration: Ability to understand that one is not the centre of the world and others have independent motives/drives   4. Mastery: Ability to use the three aspects above to define psychological problems and adequately deal with them

Metacognition is suggested to allow people to form integrated and complex ideas about self and others. Deficits in metacognition has been suggested to create disruptions in a person’s ability to form these complex ideas about mental states and integrate interpersonal information into a larger whole; thereby, disrupting the process required to construct meaning and form a sense of self. Metacognition is also suggested to be necessary for successful adaptation to a changing social world, and has been found to play a critical role in how one understands and copes with a life-altering mental illness. A new recovery-oriented treatment approach, known as Metacognitive Reflection and Insight Therapy, has been developed to address deficits in metacognition in people with a diagnosis of schizophrenia. The findings from this research has revealed that improving metacognition resulted in these individuals experiencing an enhanced sense of self, as well as an improved: course of recovery, ability to engage in self-reflectivity, and overall quality of life. Adopting this treatment approach for people with a severe mental illness is suggested to enhance their self-experience and recovery by improving their capacities for metacognition and, thereby, allowing them to reconstruct their sense of self.

Although this treatment was developed with a view to improving the metacognition of people with a severe mental illness, it appears that a coherent sense of self lies at the core of who we are and, therefore, a client’s mental well-being and recovery process. Depending on the severity of the mental illness, the disruptions to this core may be more or less. My sessions can be tailored to use Metacognitive Reflection and Insight Therapy principles to reconstruct a client’s sense of self.

MERIT Institute provides some more detailed information about this treatment approach: https://www.meritinstitute.org/

References

Bargenquast, R., & Schweitzer, R. (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(3), 338-356. doi: 10.1111/papt.12019

Dimaggio, G., & Lysaker, P. H. (Eds.). (2010). Metacognition and severe adult mental disorders: From research to treatment. New York, NY: Routledge.

Drake, R. E., & Whitley, R. (2014). Recovery and severe mental illness: Description and analysis. The Canadian Journal of Psychiatry, 59(5), 236-242. Retrieved from https://www-ncbi-nlm-nihgov.ezp01.library.qut.edu.au/pmc/articles/PMC4079142/?tol=pmcentrez

Lysaker, P. H., Carcione, A., Dimaggio, G., Johannesen, J. K., Nicolo, G., Procacci, M., & Semerari, A. (2005). Metacognition amidst narratives of self and illness in schizophrenia: Associations with neurocognition, symptoms, insight and quality of life. Acta Psychiatrica Scandinavica, 112(1), 64-71. doi: 10.1111/j.1600-0447.2005.00514.x

Lysaker, P. H., Glynn, S. M., Wilkniss, S. M., & Silverstein, S. M. (2010). Psychotherapy and recovery from schizophrenia: A review of potential applications and need for future study. Psychological Services, 7(2), 75-81. doi: 10.1037/a0019115

Lysaker, P. H., Pfenninger, D. T., & Klion, R. E. (n.d.). Metacognitive reflection and insight therapy. Retrieved from http://www.meritinstitute.org/templates/default/images/MERIT_Overview.pdf