Metacognition in Psychosis- Review

Journal of Experimental Psychopathology

January-March 2019: 1–12
Metacognition and recovery in ª The Author(s) 2019
DOI: 10.1177/2043808718814992
journals.sagepub.com/home/jepp
schizophrenia: From research to the
development of metacognitive reflection
and insight therapy

Paul H. Lysaker
Indiana University School of Medicine, USA

Marina Kukla
Indiana University–Purdue University, USA

Jenifer L. Vohs
Indiana University School of Medicine, USA

Ashley M. Schnakenberg Martin

Indiana University Bloomington, USA

Kelly D. Buck
Roudebush Veteran Affairs Medical Center, USA

Ilanit Hasson Ohayon

Bar-Ilan University, Israel

Abstract
Metacognition refers to a spectrum of activities which spans from noticing discrete experiences to synthesizing
them into a larger sense of the self and others. Evidence suggesting that deficits in metacognition are broadly
present in schizophrenia and represent a potent barrier to recovery from schizophrenia has led to increasing
interest in the development of metacognitively oriented treatments. In this article, we will describe the
development of one such treatment, metacognitive reflection and insight therapy (MERIT), an integrative
form of psychotherapy defined by eight core elements. We will first discuss the concept of metacognition
as a means to operationalize the processes which enable persons to have a sense of themselves and others
available for reflection and that can then serve as the basis for effective and agentic responses to psychosocial
challenges. We will then discuss methods for assessing metacognition, the development of MERIT as a
treatment that targets metacognition, and how MERIT compares with other treatments. Next, we will
discuss empirical support for MERIT’s role in recovery including its potential to assist persons to develop
their own personally meaningful sense of their challenges and then decide how to effectively respond to those
challenges and manage their own recovery.

Corresponding author:
Paul H. Lysaker, Roudebush VA Medical Center, Indiana University School of Medicine, Day Hospital 116H, 1481 West 10th Street,
Indianapolis, IN 46202, USA.
Email: plysaker@iupui.edu

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2 Journal of Experimental Psychopathology

Keywords
Insight, metacognition, metacognitive reflection and insight therapy, negative symptoms, psychosocial rehabi-
litation, recovery, schizophrenia, self, social cognition

Date received: 11 September 2018; accepted: 25 October 2018

Kauffmann-Muller, & Bruant, 2001), development

Metacognition and recovery in (Kurtz & Borkowski, 1987), attachment (Main,
schizophrenia 1991), and psychopathology (Dimaggio, Montano,
Metacognition is a core process supporting ongoing Popolo, & Salvatore, 2015; Lysaker & Klion, 2017).
self-reflection, adaptation, and cooperation with oth- It has been operationalized in many different ways
ers across the lifespan. The realization that metacog- and used for multiple purposes. Metacognition has
nitive abilities or capacities differ between persons been used to refer to self-regulated learning (Dins-
has offered the possibility to explain particular fea- more, Alexander, & Loughlin, 2008), attitudes about
tures of schizophrenia spectrum disorders, such as the beliefs (Wells, 2008), awareness of one’s own reason-
unawareness of the illogicality of delusional beliefs ing processes (Moritz et al., 2014), confidence in cog-
(Moritz et al., 2014) or the failure to accurately nitive processes (Yeung & Summerfield, 2012), and
appraise personal limitations (Silberstein, Pinkham, the development of the shared awareness of oneself
Penn, & Harvey, 2018). Difficulties with metacogni- and others (Dimaggio et al., 2015; Semerari et al.,
tive function likely have even broader deleterious 2003). Other efforts have sought to distinguish differ-
effects on wellness, as they impede persons’ ability ent kinds of metacognition from one another on the
to make sense of their own personal psychosocial basis of the goal of their behaviors, for example,
challenges and then to decide how to manage those whether they involve planning, self-monitoring, and
challenges and direct their own recovery (Lysaker, error detection and knowledge about strategies for
Hamm, Hasson-Ohayon, Pattison, & Leonhardt, responding to challenges (Tarricone, 2011).
2018). This latter possibility has led to increasing In one effort to detangle the rapidly expanding
interest in the development of recovery-oriented treat- work on metacognition, Moritz and Lysaker (2018)
ments that assist persons to recapture their metacog- returned to one of the first definitions of metacogni-
nitive abilities and, therefore, more effectively tion by Flavell (1979). They noted that in Flavell’s
manage their lives and achieve higher quality of life paper, metacognition was offered as an umbrella term
over time (Lysaker, Glynn, Wilkniss, & Silverstein, to describe what is at play when humans continuously
2010). think about themselves and their responses to what is
In this article, we will describe the development of transpiring as they act in the world. They also noted
one such treatment, metacognitive reflection and that even in the early definitions, metacognition was
insight therapy (MERIT) (Lysaker & Klion, 2017). described as more than a purely cognitive phenom-
We will first discuss the concept of metacognition and enon; metacognition appeared as a construct that
its relationship to self-experience and agency. We will could be readily linked to a long history of philoso-
then discuss methods for assessing metacognition and
phical and psychological considerations of what is
the development of MERIT and describe several ways
involved as persons are aware of and reflect upon
in which MERIT converges with and diverges from
subjective experience.
other well-established treatments. Next, we will dis-
Piecing together these early definitions and later
cuss empirical support for how MERIT may promote
psychological research on health and interpersonal
recovery. Finally, future directions for research and
wellness, an integrated model of metacognition has
treatment development will be discussed.
been proposed in which metacognition is a spectrum
of activities that mutually influence one another.
The concept of metacognition These activities range from the awareness and reflec-
Metacognition has been a focus of study by many tion about specific singular immediate experiences to
different areas of psychology over the last 30–40 a larger more complex multifaceted sense of self and
years. It has been a key variable in research in edu- others (Lysaker, Zalzala, et al., 2018). In this sense,
cation (Flavell, 1979), cognition (Bacon, Danion, metacognition includes both noticing an isolated
Lysaker et al. 3

thought or bodily sensation (e.g., “I feel sad” or “I quantified in terms of correct and incorrect responses.
don’t trust a particular person”), as well as a larger However, since metacognition is foremost a process
sense of oneself (e.g., “I am having a hard time in my of integration, as it is concerned with how information
life now because of the death of a loved one”). Impor- is organized and fits together and not with the abso-
tantly, the larger sense of self is in part built from the lute correctness of any given judgment, it cannot be
smaller, singular atoms of experience and also serves characterized by proportions of correct or incorrect
as a basis for interpreting and integrating these atoms responses. In response to this dilemma, the Metacog-
of experience. nition Assessment Scale-Abbreviated (MAS-A) was
Metacognition accordingly consists of processes developed in 2004 (Lysaker et al., 2005) to assess the
which are primarily integrative in nature which bring complexity of the sense of self and others as it appears
together pre-reflective and reflective, embodied, and within spontaneous speech samples. The MAS-A was
cognitive experience in response to what is emerging an advance from the MAS (Semerari et al., 2003)
in the moment (Lysaker et al., 2018). While metacog- which assessed frequencies of metacognitive acts
nition is a platform for reflection, it is both automatic within a psychotherapy session. The MAS-A specifi-
and intersubjective, meaning metacognition usually cally quantifies the extent to which an integrated vs.
arises naturally rather than effortfully and is tied to fragmented sense of self and others is formed within a
others who might hear or respond to the contents that personal narrative of participants’ lives and psycho-
emerge from it (Mascolo, 2016; Stern, 1985). Thus, social challenges. Following the original structure of
metacognition is a key aspect of human adaption. It is the MAS, which allowed for separate assessments
a basis for agency as it is necessary for an enduring of self-reflectivity, awareness of others, awareness
sense of our abilities to respond in a world of complex of one’s community (decentration), and use of their
and changing contingencies (Lysaker & Klion, 2017).
integrated unique sense of self and others to identify
Metacognitive processes are also foundational for
and respond to psychosocial challenges and distress
intimacy, as they allow us to have an immediate sense
(mastery), the MAS-A similarly generates four sepa-
of ourselves in the moment which is fluid and respon-
rate scores which reflect each of these domains.
sive to the people around us or about to be around us
Within this rubric, mastery notably deviates concep-
in the moment. This is not to say that interpersonal
tually from others, more purely cognitive definitions
relationships and first-person experience are not pos-
of metacognition as it pertains to action. Mastery,
sible with lesser metacognitive capacities, but that
with lesser metacognitive capacities the experience however, is understood as fundamentally metacogni-
of self and others becomes more and more fragmen- tive in nature as it represents enacted metacognitive
ted. For example, with lower levels of self- processes which themselves then become a subject for
reflectivity, persons might be aware of individual reflection.
thoughts but have no sense of how they relate to one Concretely, raters read a transcript and for the
another over time or to specific events within the scales which pertain to sense of self, others, and
larger environment. decentration determine the first level which partici-
pants failed to demonstrate adequate metacognitive
capacity. The level below that or the last level in
Methods for the quantitative which participants were judged to have adequate
assessment of metacognition in metacognitive capacity is the score offered for that
schizophrenia: An iterative relationship scale (e.g., if a participant was not judged to be able
between measurement and treatment to perform the metacognitive activities described by
While the relationship between metacognition and level “5” of the Self-reflectivity scale but were judged
health is intuitive, the measurement of metacognition to adequately perform levels “1” through “4,” a score
poses several dilemmas. In particular, cognitive abil- of “4” would be offered). For the mastery subscale,
ities are generally measured in terms of performance each level is conceptualized as requiring a higher
on tasks in which there are correct and incorrect level of metacognitive capacity. For this scale, raters
responses. For example, memory can be quantified identify the maximal level of mastery performed by
as the proportion of items correctly recalled or recog- the participant and that is the score for the mastery
nized and attention by the frequency of correctly iden- subscale (e.g., if the participant was judged to be
tified targets. Emotion recognition is also often capable of level “6” of mastery but not levels “7”
4 Journal of Experimental Psychopathology

through “9” then a score of 6 is offered). The scale is MAS-A naturally offered more nuanced conceptuali-
freely available from the first author. zations of targets for interventions. Accordingly,
The quantification of distinct metacognitive capa- interventions can be tailored based on the specific
cities, such as thoughts of self, thoughts of others, deficits. Third, the scales not only described treatment
decentration, and mastery, has made the development targets, but also offered direction for interventions
of a metacognitive treatment possible in four key specific to different levels of metacognitive capacity.
ways. First, it provided a means for establishing the Intuitively, any intervention that might seek to
prevalence, character, and significance of metacogni- target self-reflectivity would need to be sensitive to
tive deficits in schizophrenia. For example, one study and not exceed patients’ maximal capacities in the
found that the MAS-A scores of 166 adults with pro- moment. Using the MAS-A, a therapist can concre-
longed schizophrenia were significantly lower than tely assess a unique patient’s maximal capacity for
the MAS-A scores of a control group of 51 adults who self-reflectivity, awareness of the other, decentration,
experienced the significant social and nonpsychiatric and mastery and offer interventions or reflections that
medical adversity of HIV (Lysaker et al., 2014). Spe- call for patients to think about themselves or others at
cifically, the schizophrenia group was found to have a level within, and not beyond, their capability (Lysa-
significant struggles to form coherent accounts of (i) ker, Buck, et al., 2011). For example, a patient unable
changing emotions and subjective beliefs, (ii) the dis- to form a nuanced sense of his own emotions would
tinct emotions of others, (iii) the unique and indepen- struggle to benefit from a therapist asking him, “how
dent needs of others, and (iv) ways to respond to do you feel?,” as this query would be beyond his
psychosocial challenges beyond gross avoidance present metacognitive ability. In essence, a patient
(Lysaker et al., 2014). Similar challenges to metacog- with low self-reflectivity would be unable to form
nitive function have also been found in samples with or express such a detailed understanding of his own
first episode psychosis as well (Trauelsen et al., 2016; emotion. Instead, the therapist might ask the patient
Vohs et al., 2014). In parallel, greater levels of meta- merely to identify fragments of experience which
cognitive deficits in schizophrenia have also been could later be integrated into a larger sense of a
reported cross-culturally in comparison with groups nuanced affective state. Fourth, and finally, the
with bipolar disorder (Lysaker, Irarrázaval, et al., MAS-A scales could also provide an opportunity for
2018; Popolo et al., 2017; Tas, Brown, Aydemir, ongoing evaluation across sessions.
Brüne, & Lysaker, 2014), depression and anxiety dis-
orders (WeiMing, Yi, Lysaker, & Kai, 2015), post-
traumatic stress disorder (PTSD) (Lysaker, Dimaggio,
The development of the elements
et al., 2015), substance use (Inchausti, Ortuño-Sierra, of MERIT
Garcı́a-Poveda, & Ballesteros-Prados, 2017), and bor- Using an iterative process, clinicians and researchers,
derline personality disorder (Lysaker et al., 2017) as including psychologists, nurse practitioners, and psy-
well as others without any psychiatric condition (de chiatrists with humanistic existential, rehabilitative,
Jong, van Donkersgoed, Renard, et al., 2017; Hasson- psychoanalytic, and cognitive behavioral back-
Ohayon et al., 2015). Deficits in metacognition grounds, have used the research noted earlier as the
among those with schizophrenia have also been found basis for the design of a treatment that would address
to potentially influence concurrent function (Bröcker metacognitive deficits. An early decision was that this
et al., 2017; Buck et al., 2014; Kukla, Lysaker, & treatment would be in the form of a measurable set of
Salyers, 2013; Lysaker, McCormick, et al., 2011; therapist behaviors that should occur within a session.
Snethen, McCormick, & Lysaker, 2014) and prospec- These behaviors were intended to reflect and go
tive function (Luther et al., 2016; Lysaker, Kukla, beyond the common factor by describing activities
et al., 2015; McLeod, Gumley, MacBeth, Schwan- which should help patients to engage in metacognitive
nauer, & Lysaker, 2014), independent of general lev- acts. Within and across sessions, the therapist is
els of psychopathology or neuropsychological expected to provide interventions that match an indi-
function across the majority of these studies. vidual patient’s unique metacognitive capacity and
Second, as research with the MAS-A has detected so, with time, promote increasingly greater levels of
and characterized how metacognitive deficits affect metacognitive capacity. It was also decided that this
the experience of the self, others, one’s community, should be an integrative form of therapy, and thus, its
and oneself as an agent in the world, the scales of the elements should be ones that could be incorporated by
Lysaker et al. 5

humanistic, cognitive, and dynamic therapists without issues or patients successfully thinking about them on
violating core assumptions of their approaches. their own in the presence of the therapist (Lysaker &
Later named MERIT by colleagues in the Nether- Klion, 2017).
lands (Lysaker & Klion, 2017), this treatment was The second class of elements was referred to as the
conceptualized as recovery-oriented. MERIT also process elements. These elements share a joint focus
proposes that the patient herself is required to make by therapist and patient on interpersonal and psycho-
sense of her challenges and determine how she might logical processes within the session, which concep-
move toward and take charge of her own wellness. tually support the reflections occurring in the first four
The therapy is integrative in the sense that it can be elements. The first of these process elements (element
employed by therapists from different backgrounds 5) requires reflection upon the therapeutic alliance or
without needing to adapt a different professional iden- the qualities of the relationship in which the patient
tity. It was believed that these qualities would allow and therapist were jointly thinking about the patient
for a holistic treatment that could be flexibly deliv- agenda, patient’s reactions to the therapist, and patient
ered by many different kinds of therapists and in narrative and struggles. The second of the process
response to patients with many different kinds of elements (element 6) requires explicit discussion of
needs. In contrast to problem-, symptom-, or the effects of the session on the mind and body of the
technique-focused treatments, MERIT sought to be patient. For example, as a result of the session, are
an internally consistent treatment which could look there different thoughts in the mind of the patient or
very different from patient to patient, based on the different feelings in his or her body? The purpose of
needs of patients and their phase of recovery. MERIT the process elements was less to “fix” any problems
thus intentionally avoids imposing a curriculum or set with the relationship or make sure progress was
of predetermined activities which could hamper occurring, but instead to promote awareness and
reflection and disrupt the development of understand- reflection about what was happening and why.
ing between patients and therapists. Together, the process elements were intended to allow
Through the iterative process described earlier, an reflections about the larger environment which was
operational definition of MERIT was developed supporting or hampering reflection. Adequate thera-
which consisted of the presence, within any given pist adherence was defined in terms of either multiple
session, of sufficient levels of eight elements, which attempts to think together about these processes or
while defined independently, should synergistically patients successfully thinking about them on their
influence the growth of metacognitive capacity (Lysa- own (Lysaker & Klion, 2017).
ker & Klion, 2017). These elements were divided into The final class of elements was referred to as the
three classes: content, process, and superordinate. The superordinate elements. These elements offered prin-
first class of elements was linked together by virtue of ciples based on the MAS-A for matching interven-
their focus on content. These elements call for explicit tions to patients’ maximal metacognitive capacity in
attention to the development of a joint understanding terms of reflections about the self and others (element
of patients’ agendas or what patients are wishing and 7) and mastery (element 8) or the use of metacognitive
seeking during or across sessions (element 1); knowledge to actively and effectively respond to psy-
patients’ experience of therapists’ thoughts and chosocial challenges (Lysaker & Klion, 2017). As a
experiences within session (element 2); patients’ nar- whole, the superordinate elements were intended to
ratives or experience within the flow of their life ensure that reflections about content or process, as
rather than abstractions about experiences (element defined in the first six elements, were tailored to
3); and recognizable psychological challenges which patients’ unique levels and, therefore, maximally sti-
are confronting the patient (element 4). As a whole, mulated metacognition while not posing thoughts that
the first four content elements were conceptualized as were too complex to be useful for patients. Here, the
allowing for a platform for continuous reflection in rubric provided by the MAS-A for the assessment of
which patients could seek out and form a sense of self-reflectivity, awareness of the other, and mastery is
their own complex and changing set of needs as recommended as means for assessing patients meta-
unique beings within the flow of their lives and the cognitive capacity in the moment and tailoring inter-
painful struggles life has and is posing for them. Ade- ventions which match that capacity. Adequate therapist
quate therapist adherence was defined in terms of adherence was defined in terms of therapists either
either multiple attempts to jointly think about these correctly assessing patients’ metacognitive capacities
6 Journal of Experimental Psychopathology

and offering appropriate interventions across the Ohayon, 2018). Thus, in MERIT, the cognitively
course of the session or shifting their interventions oriented therapist needs to see that complexity of any
following inaccurate assessments of patients’ metacog- new sense of, or increased awareness of, cognitive
nitive capacity (Lysaker & Klion, 2017). processes is as important as cognitive content. In
Training in MERIT requires formal training in the addition, superordinate elements of MERIT indicate
basic elements, completion of exercises focused on that treatment should be tailored to an individual’s
mastering the intervention framework, followed by measured level of metacognitive capacity; this would
several months of consultation around practice with also require additional considerations from therapists
active psychotherapy cases. All of these are available who are most comfortable with many manualized
from the MERIT institute (2018). cognitive behavioral therapy treatments which do not
take metacognitive capacity into account. Finally, in
terms of outcomes, MERIT can be seen to make
Overlap and divergence with
demands on therapists that go beyond supportive and
supportive and manualized cognitive cognitive therapies in its explicit focus on the unique
treatments construction of a sense of psychosocial challenges and
As noted earlier, MERIT was intended to be integra- persons’ self-direction and self-management, rather
tive in nature and thus something that could be incor- than an emphasis on symptoms or more discrete con-
porated within other approaches without violating structs (e.g., coping skills).
their fundamental assumptions. Indeed, considered
alongside supportive therapy and traditional and
third-wave cognitive therapies applied to complex
Overlap and divergence with
mental health conditions, MERIT shares several key humanistic and dynamic treatments
commonalities. As summarized in Table 1, MERIT Considering the integration of MERIT with humanis-
seeks to describe measurable therapist behavior tic and psychodynamic treatments, like most huma-
related to content, as well as process, but includes nistic and psychodynamic treatments, MERIT rejects
additional requirements that those behaviors be the prescription of predetermined exercises or thera-
adjusted according to dynamic and in-the-moment peutic activities beyond merely relating to and con-
assessments of metacognitive capacity. MERIT, sim- versing with patients in the moment. Also like these
ilar to supportive and cognitively oriented treatments, therapies, it is interested in holistic self-experience
is also focused on beliefs and awareness of cognitive and patterns across the lifespan, as well as reflection
processes as well as the development of the therapeu- as an intersubjective process. MERIT further shares a
tic alliance. Like compassion focused therapies lack of concern with symptoms and an emphasis on
(Laithwaite et al., 2009), it is deeply concerned with meaning, focusing on the ability to form a more inte-
how persons regard themselves and develop a sense of grated sense of self and others in order to become
self direction. In contrast, MERIT includes a broader better able to make sense of and respond to distress.
holistic examination of embodied and pre-reflective In contrast, MERIT may stretch the work of huma-
experiences and their relationship to cognition and the nistic and psychodynamic therapists as it requires that
broader patterns of behavior across a lifespan which the approach to the issues of meaning and experience
imbue life circumstance and challenges with their be sensitive and titrated to patients’ metacognitive
unique meanings. There is also explicit concern with capacities (Lysaker, Zalzala, et al., 2018). MERIT
joint reflection as an intersubjective process rather requires a step beyond these treatments as usually
than an objective or subjective process. practiced, in that it conceptualizes metacognitive def-
Concerning mechanisms of action, MERIT is con- icits as limiting the degree of complexity with which a
sistent with these treatments in several ways. MERIT person can find meaning. MERIT imposes a rubric of
focuses on helping patients think differently about assessment and intervention meant to help persons
themselves and others, as well as increasing aware- maximally make sense of what they face, but then
ness of basic cognitive processes. However, MERIT also to promote growth in metacognitive capacity.
distinguishes itself regarding the aim to facilitate There is nothing in MERIT that would be inconsistent
patients being able to form a more integrated sense with the possibility that wellness can proceed from
of self and others and to use that information to adap- self-actualization or coming to terms with emotional
tively face life’s challenges (Lysaker & Hasson- and psychological conflicts; however, in MERIT, it is
Lysaker et al. 7

Table 1. Convergence and divergence of MERIT from manualized supportive and cognitive therapies.
Third-wave CBT
Supportive (e.g., ACT and
psychotherapy CBT for psychosis mindfulness) MERIT
Manualized by Content Content Content Content
Process Process
Metacognitive capacity
Foci Content Current Beliefs and Beliefs and Beliefs and behaviors
dilemmas behaviors behaviors
Cognitive process
Cognitive processes
Holistic experience in the
moment
Patterns of experience across a
life
Process Therapeutic Therapeutic alliance Therapeutic alliance Therapeutic
alliance alliance
Intersubjective experience of
therapist and therapist’s
mental content
Change Problem- Problem-solving Problem-solving Adaptive coping and problem-
mechanisms solving skills skills and adaptive skills solving to face life’s challenges
coping
Adaptive beliefs Adaptive beliefs Adaptive beliefs
Awareness discrete Awareness of cognitive
of cognitive processes and patterns over
processes time
Heightened metacognitive
capacity
Outcomes Immediate Feeling Awareness of Awareness of beliefs Broader awareness of beliefs and
supported beliefs, coping and cognitive cognitive processes of self and
with symptoms processes others
Synthesis of experience into a
larger sense of self and others
Personalized account of
recovery
Long term Reduction of Symptom reduction Symptom reduction Self-direction and
distress and coping and coping self-management
Note. MERIT: metacognitive reflection and insight therapy; CBT: cognitive behavior therapy; ACT: acceptance and commitment therapy.

the complexity of any new emergent sense of self and treatment (de Jong, van Donkersgoed, Timmerman,
others that is again as important as the content of et al., 2018; Vohs et al., 2018). Similar rates of treat-
those new ideas of the self or others. ment acceptance were also reported in an open trial
of a metacognitively oriented psychotherapy that
conformed to the elements of MERIT, lasting
Evidence supporting MERIT between 11 months and 26 months offered to 11
Given dropout rates in trials of dynamic psychothera- persons with schizophrenia (Bargenquast &
pies for psychosis decades ago (Gunderson, 1980), Schweitzer, 2014) and in another open trial of a
any potentially long-term treatment has lived under shorter 12-week course of MERIT offered to 12
the shadow of questions about its acceptability and adults with schizophrenia (de Jong, van Donkers-
feasibility. To date, two randomized controlled trials goed, Pijnenborg, & Lysaker, 2016).
of 6 and 8 months of MERIT, respectively, have Beyond controlled trials, case studies conducted
demonstrated that between two-third and three-fifth under routine clinical conditions have also reported
of patients randomized to receive MERIT completed that a broad range of patients with very different
8 Journal of Experimental Psychopathology

clinical presentations, as well as profiles of strengths to recovery, interest has arisen in developing forms of
and needs, including heightened levels of negative psychotherapy that might enhance metacognition.
symptoms, comorbid substance misuse, cognitive dis- In this article, we have reviewed the development
organization, depression, and lack of insight can ben- and early exploration of one such therapy, MERIT.
efit from MERIT (Arnon-Ribenfeld, Bloom, et al., This therapy seeks to stimulate metacognition at
2017; de Jong, van Donkersgoed, Aleman, et al., optimal levels in light of individual patients’ meta-
2016; Dubreucq, Delorme, & Roure, 2016; Hamm cognitive capacity in a given moment, leading to the
& Firmin, 2016; Hasson-Ohayon, Kravetz, & Lysa- eventual development of greater metacognitive
ker, 2017; James, Leonhardt, & Buck, in press; Leon- capacities. These enhanced metacognitive capacities
hardt et al., 2016; Leonhardt, Ratliff, & Buck, 2018; are presumed to allow patients to develop their own
Van Donkersgoed, De Jong, & Pijnenborg, 2016). In coherent and personally meaningful accounts of the
contrast to other more supportive therapy experi- challenges they face and how they want to respond
ences, patients who received MERIT, whether via to them to move toward recovery. Preliminary evi-
routine care (Lysaker, Kukla, et al., 2015) or within dence supports its acceptability and potential to lead
a clinical trial (de Jong et al., 2017), reported the to meaningful clinical change among unique
development of a sense of personal agency, connec- patients with no formal or anecdotal reports of
tions with one’s own unique history, and a greater adverse side effects.
capacity to tolerate and manage painful affects and Importantly, there are limitations. Larger rando-
emotion. mized controlled trials are needed in more diverse
Concerning treatment outcomes, the case work settings with wider ranges of patients. For example,
reported earlier indicates that patients receiving while case work suggests MERIT may be applied to
MERIT can develop and meaningfully attain indivi- address the needs of adults with borderline personality
dualized recovery-oriented goals as they make sense disorder (Buck, Vertinski, & Kukla, 2018; Vohs &
of their psychosocial challenges and then decide how Leonhardt, 2016), rigorous trials are needed in per-
they want to respond to and manage those challenges sons diagnosed with these and other forms of signif-
across different phases of recovery (Hamm & Firmin, icantly disabling mental illness. Some metacognitive
2016; Hasson-Ohayon et al., 2017; Hillis et al., 2015; deficits may be secondary to cognitive deficits and it
James et al., in press; Leonhardt et al., 2016; Leonhardt is unclear whether there is a basic level of neurocog-
et al., 2018; Van Donkersgoed et al., 2016). This case nitive functioning required for MERIT to be accepta-
work has also reported evidence of significant ble and potentially helpful to patients with more
improvements in metacognition across treatment, as profound limitations forms of cognitive impairment.
assessed with the MAS-A (Arnon-Ribenfeld, Hasson- Additionally, the general psychometric properties of
Ohayon, Lavidor, Atzil-Slonim, & Lysaker, 2017; the MAS-A have not been reported in general clinical
Hamm & Firmin, 2016; Hasson-Ohayon et al., settings though several studies are currently underway
2017; Hillis, Bidlack, & Macobin, In Press; Hillis exploring this issue.
et al., 2015; James et al., in press; Leonhardt et al., Work is also needed to explore a range of more
2016; Leonhardt et al., 2018; Lysaker, Buck, & nuanced issues related to the practice of MERIT.
Ringer, 2007; Van Donkersgoed et al., 2016). To date, First, more work is needed to examine the integrative
one study has also suggested that the clinical, psycho- nature of MERIT and its utilization by therapists from
social, and metacognitive gains in MERIT persist for different perspectives. For example, it is unknown in
follow-up periods of several years (Schweitzer, Gre- what ways MERIT offered by a cognitive behavioral
ben, & Bargenquast, 2017). therapist would differ from the therapy of a humanis-
tic or psychodynamic psychotherapist. A second issue
concerns the need to develop more explicit models
Summary and future directions which describe how and when effortful and automatic
Metacognition refers to a range of processes which processes and cognitive and embodied experiences
enable human beings to have a sense of themselves come together to form a sense of self or the other.
and others which is available to them within the flow Self-experience is necessarily a reflection of the inter-
of life. With mounting evidence that deficits in these action of multiple facets (Lysaker & Lysaker, 2008).
processes are common in schizophrenia and are a bar- More research is needed to explore the ways in which
rier to persons defining and managing their own path MERIT may promote this with a consideration of
Lysaker et al. 9

what kinds of different needs different kinds of reflection and insight therapy (MERIT) among people
patients have. Furthermore, once one has a sense of with schizophrenia: Lessons from two case studies.
self available as a result of this, research is needed to American Journal of Psychotherapy. https://doi.org/10.
examine what enables or blocks its flexible evolution 1177/0022167818787881.
and emergence over time. For example, what are the Arnon-Ribenfeld, N., Hasson-Ohayon, I., Lavidor, M.,
pathways by which persons gain a more robust and Atzil-Slonim, D., & Lysaker, P. (2017). The association
stable sense of themselves that can withstand contra- between metacognitive abilities and outcome measures
diction and conflict and meaningfully respond to the among people with schizophrenia: A meta-analysis.
complex realities present in all of our biological, European Psychiatry, 46, 33–41.
social, and political environments? Regarding other Bacon, E., Danion, J. M., Kauffmann-Muller, F., & Bruant,
forms of symptoms, including distress and positive A. (2001). Consciousness in schizophrenia: A metacog-
symptoms, it is assumed that with the emergence of nitive approach to semantic memory. Consciousness
meaning persons become better able to tolerate pain and Cognition, 10, 473–484.
and are less likely to rely on idiosyncratic explana- Bargenquast, R., & Schweitzer, R. D. (2014). Enhancing
tions of distress and challenge but this remains to be sense of recovery and self-reflectivity in people with
formally tested in clinical settings. Research is cur- schizophrenia: A pilot study of metacognitive narrative
rently underway examining whether metacognition is psychotherapy. Psychology and Psychotherapy: Theory,
in fact a moderator of the link between distress and Research and Practice, 87, 338–356.
positive symptoms. Bröcker, A. L., Bayer, S., Stuke, F., Giemsa, P., Heinz, A.,
Finally, while we have focused on outcome in Bermpohl, F., . . . Montag, C. (2017). The Metacogni-
terms of patients’ recovery, it is also relevant how this tion Assessment Scale (MAS-A): Results of a pilot study
therapy affects therapists and contributes to or com- applying a German translation to individuals with
plicates their long-term practice. This may not be a schizophrenia spectrum disorders. Psychology and
therapy for all therapists. For some, responding to the
Psychotherapy: Theory, Research and Practice, 90,
meanings being formed in disorganized discourse
401–418.
may be threatening and overwhelming. It may require
Buck, K. D., McLeod, H. J., Gumley, A., Dimaggio, G.,
that therapists are able to think in the moment, accept
Buck, B. E., Minor, K. S., . . . Lysaker, P. H. (2014).
their own confusion and vulnerability, and to use their
Anhedonia in prolonged schizophrenia spectrum
creativity to understand the profound suffering of the
patients with relatively lower vs. higher levels of
patient. However, for many therapists, this process
depression disorders: Associations with deficits in social
unlocks creativity and may help to prevent career
cognition and metacognition. Consciousness and Cog-
burnout. In research, we are now analyzing and
nition, 29, 68–75.
exploring how MERIT may play a role in the profes-
Buck, K., Vertinski, M., & Kukla, M. (2018). Metacogni-
sional well-being of psychotherapists, acting as
another means to promote better patient outcomes. tive reflective and insight therapy: Application to a
long-term therapy case of borderline personality disor-
Declaration of conflicting interests der. American Journal of Psychotherapy. doi:10.1176/
The author(s) declared no potential conflicts of interest appi.psychotherapy.20180035
with respect to the research, authorship, and/or publication de Jong, S., van Donkersgoed, R. J., Aleman, A., van der
of this article. Gaag, M., Wunderink, L., Arends, J., . . . Pijnenborg, M.
(2016). Practical implications of metacognitively
Funding oriented psychotherapy in psychosis: Findings from a
The author(s) received no financial support for the pilot study. The Journal of Nervous and Mental Disease,
research, authorship, and/or publication of this article 204, 713–716.
de Jong, S., van Donkersgoed, R., Pijnenborg, G., & Lysaker,
ORCID iD P. H. (2016). Metacognitive reflection and insight therapy
Paul H. Lysaker https://orcid.org/0000-0002-6617-9387 (MERIT) with a patient with severe symptoms of disorga-
nization. Journal of Clinical Psychology, 72, 164–174.
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Research, 199, 75–82. Author biographies
Snethen, G. A., McCormick, B. P., & Lysaker, P. H.
Paul H. Lysaker is a Clinical Psychologist at the Roude-
(2014). Physical activity and psychiatric symptoms in
bush VA Medical Center and a Professor of Clinical Psy-
adults with schizophrenia spectrum disorders. The Jour-
chology in the Department of Psychiatry at the Indiana
nal of Nervous and Mental Disease, 202, 845–852.
University School of Medicine, Indianapolis, IN.
Stern, D. N. (1985). The interpersonal world of the infant:
A view from psychoanalysis and developmental psychol- Marina Kukla is a Clinical Psychologist and Research
ogy. New York: Karnac Books. Scientist at the HSR&D Center for Health Information and
Tarricone, P. (2011). The taxonomy of metacognition. New Communication at the Roudebush VA Medical Center. She
York: Psychology Press. is also an Adjunct Assistant Professor in the Department of
Tas, C., Brown, E. C., Aydemir, O., Brüne, M., & Lysaker, Psychology at Indiana University-Purdue University India-
P. H. (2014). Metacognition in psychosis: Comparison napolis, Indianapolis, IN.
of schizophrenia with bipolar disorder. Psychiatry
Jenifer L. Vohs is a Clinical Psychologist and a Assistant
Research, 219, 464–469.
Professor of Clinical Psychology in the Psychiatry Depart-
Trauelsen, A. M., Gumley, A., Jansen, J. E., Pedersen, M.
ment at the Indiana University school of Medicine, India-
B., Nielsen, H. G., . . . Simonsen, E. (2016). Metacogni- napolis, IN.
tion in first-episode psychosis and its association with
positive and negative symptom profiles. Psychiatry Ashley M. Schnakenberg Martin is a Doctoral Candidate
Research, 238, 14–23. in Clinical Psychology in the Department of Psychological
Van Donkersgoed, R., De Jong, S., & Pijnenborg, G. and Brain Science at Indiana University, Bloomington, IN.
(2016). Metacognitive reflection and insight therapy
(MERIT) with a patient with persistent negative symp- Kelly D. Buck is a Clinical Nurse Specialist at the Roude-
toms. Journal of Contemporary Psychotherapy, 46, bush VA Medical Center, Indianapolis, IN.
245–253.
Ilan Hasson Ohayon is a Rehabilitation Psychologist,
Vohs, J. L., & Leonhardt, B. L. (2016). Metacognitive Associate Professor and Co-Director of the community
reflection and insight therapy for borderline personality clinic at the department of psychology at Bar-Ilan Univer-
disorder: A case illustration of an individual in a long sity in Israel. Her research and clinical work in the field of
term institutional setting. Journal of Contemporary Psy- mental health mainly concerned with diffrent aspects of
chotherapy, 46, 255–264. coping with illnesses, especially serious mental illnesses.