Introduction

Contemporary research has suggested that meaningful recovery from schizophrenia is possible and requires that persons actively make sense of their condition and lives and direct their own recovery (Lysaker and Buck 2006; Buck et al. 2013). This suggests that treatment may need to go beyond advice giving or teaching of skills and instead offer opportunities for patients to reflect and then make decisions based on those reflections.

However, one barrier to helping persons think about their experiences with mental illness and what they want in life are metacognitive deficits. Metacognition in this sense refers to a spectrum of mental activities that involves reflective capacities which range from discrete acts in which people recognize specific thoughts and feelings to more synthetic acts in which an array of intentions, thoughts, feelings, and connections between events are integrated into larger complex representations (Lysaker et al. 2013; Semerari et al. 2003). Synthetic forms of metacognition can be distinguished from more traditional elements of social cognition in that they occur within intersubjective discourse between people and are related to the extent to which pieces of information are coherently integrated rather than whether or not specific judgments are accurate. Research has suggested that many with schizophrenia experience metacognitive deficits, that is, they struggle to integrate information into a rich sense of self and of others and that those deficits are a barrier to range of outcomes (Lysaker et al. 2015).

Accordingly, several authors have suggested that recovery oriented treatment should include forms of psychotherapy that could enhance metacognitive capacity (Lysaker and Dimaggio 2014; Lysaker et al. 2010; Lysaker et al. 2011). In particular, efforts have been made to formalize the basic principles of such a therapy (e.g. Van Donkersgoed et al. 2014). To date, evidence supporting this approach includes case studies (Buck and Lysaker 2009; Lysaker et al. 2007; Salvatore et al. 2012; Hillis et al. 2015) and two small open trials (Bargenquast and Schweitzer 2014; De Jong et al. submitted).

One limitation of the casework to date is that it has not yet discussed a case in which a patient achieved high levels of metacognitive capacity. This work has discussed, for example, interventions for helping patients to achieve basic metacognitive capacity, for example, to name a psychological problem or for instance, to identify a range of affective experiences or fallibility of thought. Lacking, thus, is casework exploring the challenges and therapeutic issues when working with persons who start with a low level but are able to achieve higher levels of metacognitive capacity throughout metacognitive reflective and insight therapy (MERIT). Accordingly, this paper will present a case study of the application of MERIT, with a patient who improved to be able to engage in more complex and synthetic metacognitive acts. We first describe the basic principles of MERIT and after presenting background information, discuss how they were applied in this case. Long-term outcomes are then presented.

Treatment Approach

MERIT is a treatment approach used to facilitate the growth of metacognitive capacity through intensive individual therapy. In the therapeutic non-hierarchical relationship in which dialogue is key, therapists and patients focus on assisting patients to reflect on thoughts about themselves and others in order to enhance metacognitive capacity. In this model, the focus is on an intersubjective experience, rather than the therapist offering advice or teaching new skills. In other words, synthetic metacognitive capacity is promoted through joint reflection upon patients’ mental experiences. Interventions to stimulate metacognitive activity in MERIT are based on ongoing assessments of patients’ metacognitive functioning. MERIT conceptualizes metacognitive capacities as hierarchical. Before persons can perform complex metacognitive activities, they must be capable of performing less complex levels. Thus, patients with lesser capacities need interventions to assist them to first master basic capacities (Lysaker et al. 2011).

To stimulate metacognition, MERIT calls for eight interrelated processes within every session. These include positioning the patient’s agenda as primary, sharing of the therapist’s thoughts without disrupting dialogue, eliciting a narrative episode(s), defining a psychological problem, discussing interpersonal processes in session, evaluating progress, stimulating reflective activities about the self and others, and finally, stimulating thoughts about how best to understand and to respond to psychological and social challenges. The development of MERIT has been thoroughly described elsewhere (Lysaker et al. 2014a).

Case Illustration

Presenting Problem/Client Description

PartFootnote 1 is a Caucasian male in his sixties, raised by his maternal grandparents in a rural Midwestern town in the United States. His mother and father never married. His mother who never had custody of him visited him twice yearly at his grandparents’ home. He saw his father rarely and noted he was physically abusive. He had several half brothers and sisters whom he never knew well. There was no indication of a family history of mental illness.

In childhood, Part felt closest to his grandmother, though he noted always longing for his mother to take him home with her after their brief visits. Part had many academic and theatrical successes and awards while young, but he had difficulty making friends and fitting in with peers. He expressed how his accolades in high school gave him a sense of identity as a talented actor, but he never dated. Additionally, he had many responsibilities in the family business

After graduating from high school, Part enlisted in the Air Force and after a few years he experienced his first episode of psychosis which involved delusions that he was a subject in a secret military project and experiencing visual and auditory hallucinations. He was hospitalized during that time and given a diagnosis of schizophrenia. While he took medication for a few months, he was not aware he had a mental disorder and he did not continue his treatment.

After the military, he achieved a college degree, got married and had two sons and a daughter. He was never fully vocationally successful and explained that was because of a conspiracy by others who were jealous of him. At home, he was often angry and demanded that his opinion be accepted without question. He pushed his children to succeed academically and often limited their social interactions. He admittedly was quite controlling of his wife, whom he viewed as incapable of making decisions without his direction and guidance. For years he managed without coming to the attention of mental health professionals until he became convinced his nephew, 40 years younger than Part and his wife, was making pornographic movies with his wife and ultimately Part threatened him with a knife. His family called the police and Part was voluntarily hospitalized.

During the hospitalization, he was prescribed a low dose of an atypical antipsychotic. He still did not believe he had psychosis and despite his family’s strong denial of his suspicions, he fervently held to his convictions and believed he would be vindicated. Subsequently, he and his family were estranged; however, he desired reconciliation. He was discharged on the atypical antipsychotic, with recommendations to also engage in group therapy and weekly individual therapy. He was engaged in group therapy for approximately a year, and was involved in weekly individual therapy for over 5 years, and rarely missed a session.

Case Formulation

Diagnostically, Part’s clinical presentation met full criteria for schizophrenia. His inability to maintain work and consequent frequent moves appeared closely related to persistent paranoid delusions. There was no history of alcohol or drug abuse, or affective or non-psychiatric conditions which could explain his positive symptoms. Part appeared to have above average intelligence.

Part’s metacognitive capacity was assessed using the four scales of Metacognition Assessment Scale-Adapted (MAS-A; Lysaker et al. 2005; Lysaker et al. 2014b): “Self-reflectivity,” the comprehension of one’s own mental states, “Understanding the Mind of the Other,” the comprehension of other individuals’ mental states, “Decentration,” the ability to see the world as existing with others having independent motives, and “Mastery,” the ability to use knowledge of one’s mental states to respond to social and psychological dilemmas. The MAS-A is an adaptation of the MAS (Semerari et al. 2003) developed in collaboration with the original authors. This revealed that in terms of self-reflectivity, Part knew his thoughts were his own and had the ability to identify and distinguish his cognitive operations. However, he possessed a limited ability to acknowledge affect, only being aware of feeling angry and frustrated and was relatively unable to understand that his thoughts were subjective and fallible. In terms of awareness of the minds of others, Part knew that others had their own mental states, but he had no ability to accurately discriminate them, only believing that others were lying to or tricking him. In terms of Decentration, Part experienced himself as the center of others’ mental activities. He was unable to recognize that others could have valid and different perceptions of events than he. Regarding Mastery, Part was not able to formulate a plausible psychological problem he was facing. Although he could acknowledge being in distress, it was always the result of various forms of highly improbable mistreatment by others.

Course of Treatment

Element 1: Determining the Patient’s Agenda

The first element of MERIT calls for the therapist to seek to understand a patient’s agenda. Patients’ agendas can be described as what they are seeking during a particular encounter, or the wishes, hopes, desires, plans, and purposes they bring into each session. Patients may have multiple agendas including contradictory or unrelated agendas and may be more or less aware of those agendas. The purpose of this element is to assist patients to experience and reflect upon themselves as agentic beings who have wishes, hopes, desires, plans, and purposes.

For Part, his initial agenda was to convince the therapist that his perceptions were accurate. He would frequently insist there was a plot against him, that he was not responsible for what was happening to him, and that the truth would eventually come out. He also sought to be seen by the therapist as unusually intelligent, powerful, and deserving of admiration. To impress, he typically used unusual and sophisticated words and phrases but in inappropriate ways. Thus, his agenda was also often to avoid being known by the therapist when that knowledge did not reflect in a positive way upon him. At times, he hinted he wanted to think about inadequate feelings, but these wishes were fleeting and soon were hidden underneath material about the conspiracy against him. In response to this, the therapist did not contradict or acquiesce. She did not, for example, label these agenda as inappropriate. She verbalized awareness that those were his wishes and continued to try to get to know him, openly acknowledging being known was something with which Part was not comfortable. At times the therapist felt some sense of sadness on her own as she realized how much of Part’s life was a search for others to admire him and then how readily he quickly rejected others when that need was unmet.

Over time, as Part remembered and discussed more events in his life, he seemed to tolerate the therapist’s interest in his story, his understanding of her intentions improved, and his agenda began to also involve exploring his emerging emotions and dealing with resultant pain. His focus changed from detailing prior insults to wondering what he thought about himself. He began to express feeling desperately empty, sad and lonely, with little sense of who he was as a person, often sobbing. He agreed that anger gave him a sense of control and direction throughout his life, but now without it, he wanted to feel in control again but did not know how. Again, the therapist did not respond by trying to minimize or ameliorate the pain. In keeping with Part’s agenda, she merely sought to articulate in an increasingly nuanced manner what that agenda was and how it was changing. When that agenda shifted back to asserting the truth of his delusions, she often experienced frustration as it seemed like poignant gains had been at least temporarily lost.

Overtime, with more identification and expression of painful feelings, Part began to express his desire to be loved by the therapist and at times looked lustfully at her. In response, the therapist and Part discussed how this revealed two contradictory agendas: avoiding further self-exploration by focusing on a personal relationship with the therapist and wanting to be loved in the way he had wanted his mother to love him. While the therapist indicated that a romantic connection would never occur, she did not reject these underlying agendas though at times they were uncomfortable to experience.

In summary, consistent with the first element of MERIT, the therapist constantly thought with Part about what he was seeking. The goal was not for him to find the “real” thing he wanted but instead to help him develop a sense of himself as an agentic being in the world, regardless of what he was seeking.

Element 2: The Introduction of the Therapist’s Thoughts in Ongoing Dialogue

The second element of MERIT requires the therapist to insert her own mind into the session in a meaningful way in order to promote dialogue and to encourage collaborative thought (Lysaker et al. 2011). As the goal of the first element is the growing awareness of patients’ wishes in the moment, this element focuses on development of the patient’s awareness of the therapist’s mind.

In the beginning, this involved the therapist slowly noting that in her mind she did not share Part’s delusional beliefs. This was done with care to not provoke an argument but to distinguish and introduce her own mental activities and to allow Part to realize he had a reaction to her thoughts when not identical to his own. For instance, Part once brought in a copy of an innocuous email which he felt clearly proved pornographic movies had been produced. In response, the therapist merely suggested that when she read the same email, she didn’t become convinced of anything and it was agreed that this was disturbing to Part.

Initially, there seemed to be few places where the therapist could share her own thoughts. She did nevertheless and continuously urged Part to reflect with her about his reactions to her thoughts, no matter how negative. As therapy progressed, Part not only allowed for her to share more but actively sought out her thoughts to better understand his own growing ability to view the therapist as an individual with her own thoughts and ideas. Accordingly, the therapist as a woman, mother, and grandmother, was able to use these experiences to interject her thoughts and experiences in a way that supported dialogue between the dyad without derailing Part’s agenda. In reference to his relationship with his wife, the therapist would often comment how she would feel if she had to account for everywhere she went (as he expected of his wife) or how it felt for her to be told what to do, which was accepted by the patient and jointly thought about during sessions. Being a mother herself with grown children, she would offer her thoughts about raising children and how her academic expectations for her children were similar and different than his and perhaps why that was. Notably this was not a linear process and the therapist did not expect Part to react the same way each session to the therapist. Thus, each session presented new opportunities to reflect about how Part was responding to her.

The goal of the second element was thus not to coax Part to accept the therapist’s thoughts as “true” or find the one “true” reaction to the therapist. Instead what the therapist did through these activities was to help Part realize he had responses to the therapist’s thoughts and then to reflect upon them. This enabled Part to see himself more clearly as someone whose mind was affected when he encountered the mind of the therapist, and ultimately being able to use his reaction to her thoughts to think about himself and others.

Element 3: The Narrative Episode

The third element of MERIT requires therapists to elicit and promote thought about narrative episodes to form a contextualized mutual understanding of patients as unique beings (Dimaggio et al. 2012). This was particularly important for Part, who had been disconnected from his life story for many years and who had little sense of an identity except as someone with abstract attributes such as intelligence. Many narrative episodes throughout his life were elicited multiple times leading to a slowly more detailed and nuanced account of his life. Overtime, the dyad began to mutually connect narrative episodes and themes began to emerge. A core narrative of his life was being left by his mother, and feeling unlovable but unable to express his related sadness because it was not accepted by his grandparents. Feeling “all alone,” he instead focused his attention on academic and theatrical pursuits in which he sought and received external validation. A poignant narrative involved a visit with his father in which he fought back against him when was trying to punish Part, and his father responded by asking him to choose between defiance or accepting the punishment or death, which the therapist related to the incident with his nephew. Other poignant stories emerged as well including being successful as an actor in high school and subsequently “acting” in relationships with others. Details of his past work performance began to formulate a jointly created picture of one who would initially have much promise, but it would never last due to interpersonal difficulties and his delusional thoughts; thus his cherished “golden” views of himself at work began to “tarnish.”

Early on, one obstacle to obtaining narrative episodes was the temptation to mistake Part’s vague yet articulate accounts of his life as actual narratives. There was pressure from Part to agree that the therapist knew what he meant and to accept it. This required interventions aimed at assisting him to give clear examples, and for the therapist to provide scaffolding for him to offer specific and detailed narrative episodes so that the dyad could clearly understand his experiences. With time, he was often able to acknowledge his own vagueness, and anticipate the need to share details.

Over the course of therapy, the dyad accordingly developed a clearer picture of Part as a person with some successes and great pain who had avoided being known by others so they wouldn’t see him as unlovable. He offered that being able to recollect and integrate his memories about himself was helpful even though he felt quite vulnerable, and he began to express that he thought he was actually changing to be like his gentle grandfather rather than his abusive father. While not having as much access to his anger, he often felt unprotected, but began to appreciate listening to perspectives of others rather than having to be one who was expected to know everything or offer advice.

Of note, here the therapist did not seek the “true” or “real” story, nor did she treat narrative episodes as history to be systematically gathered. Instead, attention to narrative episodes allowed Part to reflect with the therapist about himself as a person whose identity had uniquely developed over time.

Element 4: The Psychological Problem

The fourth element of MERIT is the recognition of a mutually agreed upon psychological problem. Initially Part perceived others as having “problems” which were significantly implausible. He thus offered no psychological problem and no reason for being in psychotherapy. This created a dilemma for the therapist since to suggest to Part that he was wrong and that he had psychological difficulties could insult him and destroy the therapeutic relationship. In response, the therapist avoided contradicting Part’s account of how his dilemmas were the result of the malice of others but did not join him and instead continued to gather narrative details about the dilemmas as well as notice his mental state in the moment. For example, a discussion of his avoidance of painful emotions in session led to a memory of being told by his grandmother never to cry when his mother left, and it made sense to him that he had learned that lesson early and hence had avoided painful emotions throughout his life.

With time Part recognized that “the common denominator in all of these stories (about paranoia) is me” and he considered the possibility that he and the therapist could think about some role he might have played. Initially this was not an admission of responsibility, but merely a willingness to consider that possibility. This led to particularly emotional sessions in which the therapist allowed him to tolerate great pain, never attempting to take them away. As he began to reconnect with his life story, he noted how he had no “identity” and strived to be known in a particular way to others. While discussing his suspicious thoughts, the therapist would gently challenge that perhaps some of his own perceptions were not accurate and he began to discuss those perceptions in sessions while using the therapist’s mind to assist with clarifying his perceptions. Two years into therapy, he identified feelings of being unlovable, feeling like a failure and never being accepted by others or allowing himself to be known because others wouldn’t like what they saw. The therapist focused on recognizing that anger, while it had motivated him and given him a sense of power, had isolated him and made him feel more alone and empty. One session he said he’d seen a picture of a mass murderer and had horrifyingly identified with the look in the murderer’s eyes, and that he recognized that hate in his own eyes, which helped the therapist to focus on his rage but also on his expression of extreme remorse for how he’d hurt others throughout his life. In regard to his belief about the affair, the therapist would explore what would occur if it wasn’t true and he would express that to do so “would destroy me” and “I would be nothing.” Three years into therapy he began to challenge his previous delusions, and express the realization there had not been the production of pornography and there was no affair. Additionally, he began to develop a nuanced and genuine sense of identity that was not founded on the need for others to know him a certain way.

In this element the therapist did not try to find the “true problem” but to think with Part about himself as confronting difficulties which can be articulated. As in the case of the other elements, this is not a linear progress. During some sessions Part was quite vulnerable and emotional, and then the next he was convinced of his delusional thoughts and had no plausible problems. This was frustrating and felt as if key agreements had been abandoned or lost. In response to sessions where the psychological problem had been lost, the therapist responded by commenting on the difference between sessions in which he focused only on others versus himself.

Element 5: Reflecting on Interpersonal Processes as They Are Occurring within Session

The fifth element of MERIT requires that the dyad jointly think about the interpersonal processes that are occurring during the session. Whereas the first four elements assist the patient to think about their wishes, experiencing the therapist’s thoughts, and themselves as beings in the world facing challenges, this element encourages reflection about the relationship which is supporting those reflections.

In this case, the therapist consistently attempted to discern and discuss with Part who she was as an “audience” with whom he was communicating. At first, Part said she was someone to impress but also to keep at a distance. Overtime though he described her as a trusted confidant with whom he could be vulnerable as she assisted him with clarifying his thoughts, identifying painful affects, and challenging the fallibility of his thinking and later connecting narrative episodes to identify themes in his life, themes that were, at times, also present in the therapeutic relationship. For example, the therapist was open to the reality and discussion of the fact that she played multiple and contradictory roles. She made note of his lustful looks when they appeared and discussed how as an audience she was both someone to conquer romantically but also someone to belittle and objectify.

To illustrate a particularly complicated session, the therapist confronted Part with how aggressive he had been in the last session, standing too close to her as they said goodbye at the session’s end. The purpose of this involved limit setting but also served as an opportunity to discuss the relationship in which so much reflection had been occurring. In response, Part was initially penitent but when urged to be honest he discussed how the therapist was one who inspired overwhelming needs and how on that day and many others he responded with aggression, which had often resulted in severed interpersonal relationships which would leave him feeling more alone and angry. As the dyad thought about the specific kinds of needs she inspired in him he was able to see that his sessions with her felt much like his biannual visits with his mother at his grandparents’ home, which always ended with him wanting her to take him home with her but instead he was left alone with his grandparents feeling overwhelmingly empty.

Overtime, Part’s romantic feelings for the therapist lessened but didn’t disappear and it was reflected that they were perhaps a way to “save face” given his lingering needs to be cared for, which were still experienced as painful and somewhat degrading. Of note, here the goal again was not to change or resolve Part’s feelings but to establish across sessions that Part was not just thinking about himself but thinking about himself with another person.

Element 6: Reflection on Progress Within the Session

The sixth element of MERIT requires a joint reflection each session about how the patient has experienced the session. Questions like “How was our session for you today?” and “Did this go as you expected and if so was that good or bad?” were commonly asked. Often it is helpful to ask how the session is going before the end of the session. Such questions are meant to be a subject for reflection, and to express value for the patient’s experience and opinion, not merely to assess progress.

Part initially responded to these questions offering global positive remarks seeming to want to praise the therapist, hoping that she would return the praise. Consistent with his metacognitive deficits, he seemed initially unable to think about how his thoughts had changed over the session. As he was asked repeatedly, this reflection became a routine part of the session and with consistent encouragement he began to slowly wonder about what had happened besides whether the session had been “good.” These questions thus prompted Part to notice what had happened in his mind during the session and then to wonder how to describe his reaction to that. He noted specifically that he was surprised by the things he found himself thinking and feeling, particularly when he felt great sadness. He thus came to think of the sessions as more than a place to express a set of preplanned ideas but to encounter changes in his mind.

As sessions progressed he expressed curiosity at why sessions brought him such great relief, but also noted being surprised at his experience of overwhelming emptiness and need which led him to conclude he was going to die. As the therapist began to integrate his narrative episodes into a whole, he noted that therapy itself was proving to be so different than he expected with sense of himself changing which led again to the surprising reflection that he wished he had the opportunity to think about himself years ago.

Element 7: Stimulating Self-Reflectivity and Awareness of the Others’ Mind

Offering interventions to stimulate self-reflectivity and thoughts about others in an increasingly complex and integrative manner is the seventh element of MERIT. In this element patients are engaged to reflect upon their thoughts about themselves and others at the metacognitive level the patient is capable of, as operationalized through use of the MAS-A. While Part began therapy with limited self-reflectivity he developed the capacity to experience affect and understand that his thought processes were subjective and fallible. Interventions thus began to target how the world did not always accommodate his hopes and dreams and how painful that was. The therapist asked him about how his life did not go as he had wished and how his life might have been different for him at different junctures in his life. That led to a focus on specific narrative episodes in which Part was encouraged to link affects, thoughts and wishes together into a more coherent picture of him currently. For instance, he noted a conflict with a storeowner and described how changing emotions led him to assume certain things which culminated in more troubling emotions and even more far reaching conclusions. It also included more seminal events in his life including threatening his nephew. In that case Part was able to think about the specific events that happened in his mind and he could compare them to how he threatened his nephew’s life.

As Part became more able to think about himself in the context of specific narrative episodes, the therapist next focused on linking together narratives and helping him to integrate a more realistic and complex picture of himself. The dyad talked about how different events in his life were linked by themes of blaming others to explain pain, feeling empty, using anger for motivation and a sense of power and identity, having needs which were never met, and using paranoid thinking to explain his failures and fuel his anger. Of note, as his narrative became richer, delusional material vanished, as it seemed he no longer needed it to explain pain or loss.

In parallel, as he synthesized a more complex picture of himself, there were also reflections about others, including the therapist, which similarly became increasingly complex. As Part quickly was able to realize others had their own emotional reactions and sought to communicate particular things, the therapist wondered with him about the effect his behaviors may have had on others within specific narrative episodes. Again this involved everyday experiences such as the conflict with the storeowner but also how others were affected when he threatened his nephew. This then led to even deeper understanding about the complex course of the lives of his sons and daughter and how they perceived the larger world.

Of note, early in therapy, the biggest barrier to progress was the temptation to see Part as able to challenge his thinking because of the intellectual quality of his speech when he actually had no capacity to do so. The danger in focusing on challenging his fallible thinking resulted in pointless intellectualizing, when instead the interventions should have focused on his inability to make sense of his own emotional experiences. Indeed early on it became apparent that gross levels of anger and frustration were the only feelings with which Part could name. Once interventions were focused on experiencing and tolerating emotions, it more easily followed that he began to show some ability to question his own thinking, which led to synthesizing a more complex image of himself.

Element 8: Stimulating Mastery

Stimulating mastery is the final element of MERIT. This element focuses on assisting patients to develop the ability to utilize knowledge about themselves and others to respond to psychological problems and challenges. Initially, Part had no plausible challenges. He was the victim of implanted chips in his brain and his nephew’s production of pornographic movies. Because Part blamed others for his failures in a paranoid fashion, the therapist would often shift the focus of the session to him, not arguing whether or not others were the cause of his difficulties, but would focus on his mental contents and feelings, searching for some kind of psychological or social challenge they could agree upon, either in the moment or during narrative episodes. Early on, this enabled the dyad to agree that Part faced the challenge of loneliness. This paved the way to ask how Part responded to loneliness.

Here the goal of the intervention was not to find the best way to cope with the challenge but to stimulate Part to think about himself as responding to plausible challenges. For Part, initially through joint reflection he could see that the most he could in do response to loneliness was to grossly reject others and withdraw. While this was obviously an ineffective strategy, he could find no other response. With time he began to be able to imagine that he could impose specific behaviors upon himself and then to challenge the specific things he was thinking.

The next step was then to be able to use knowledge of himself and others to decide how to respond to specific dilemmas. At this point, the agreed-upon challenges were his paranoid misperceptions. When he could accept that often his perceptions were inaccurate, he would use the therapist’s mind to closely look at more current narrative episodes and make sense of them. For example, he would want to discuss a neighbor who he would immediately think was purposefully taunting him, but with the therapist’s use of Socratic reasoning, he was able to think differently and more importantly, react differently. Overtime, he would use his knowledge about his tendency to think in a paranoid fashion and react angrily, to step back and generate different hypotheses for the situation which resulted in his acting in less angry and aggressive ways.

In time, through joint reflection, it was made manifest that while he preferred to have the therapist to monitor his thoughts, that this was something he should do too. He noted then that the more he began to self-monitor, the more he had a sense of relief and “peace.” It is important to note that the suspicious beliefs did not completely dissipate, but he was able to use his knowledge of himself and others to think about the situation and react differently. With more awareness of himself and others, he even began to develop more interest in listening to others, which began to assuage his long-standing sense of loneliness.

Outcome and Prognosis

After over 5 years of therapy, the dyad decided to terminate therapy, and agreed to meet every 3 months to review medications. Throughout the course of psychotherapy, Part was prescribed a low dose antipsychotic and then a low dose antidepressant midway through treatments when emotional distress began to emerge.

The decision to terminate psychotherapy stemmed from agreement that Part had achieved his primary goal of reconciliation with his family and he had also developed the ability to manage feelings of emptiness in ways that did not lead to paranoid thoughts. While there were occasional suspicious thoughts, there were no delusions, hallucinations or negative symptoms. He was not experiencing any persistent distress and had developed positive relationships with his family and others, and began to volunteer in his church. Part noted awareness that it was still painful to not be seen in a positive light by others but indicated that this was not disabling in anyway.

Overall Part’s capacity for metacognition was observed to increase significantly. He was able to form complex and integrated ideas of himself and others which helped him sustain a sense of himself and others across narrative episodes. He also demonstrated the ability to use metacognitive knowledge of himself and others to decide how to think about and respond to psychological and social challenges. Interestingly, as these abilities emerged he developed the capacity for Decentration. In particular, he first noticed that others had valid and differing perspectives and then could see the events occurring around him resulting from complex factors which varied according to the individuals involved. From a distance, Part can thus be seen as having achieved much more than learning skills or finding ways to combat symptoms. Over the course of treatment, he developed richer and more complex ideas about himself and ultimately could take charge of his own recovery and experience a fully acceptable quality of life. Since the end of therapy and the writing of this paper, Part has sustained his gains.

There are limitations to this case illustration. More work is needed with formal assessments of metacognition and psychopathology overtime in both case studies and controlled trials of this treatment. It is important to note that this case was studied over 5 years, and therefore, it is unclear how useful this treatment might be for settings which offer shorter time commitments. Future studies might continue to explore the interplay of different forms of metacognition assessed in this work.