Targeting Insight in First Episode Psychosis: A Case Study of Metacognitive Reflection Insight Therapy (MERIT)

One aspect of schizophrenia contributing to its complexity is the lack of insight individuals often have into their illness. While poor insight is prevalent throughout the course of the illness, more severe levels are associated with first-episode psychosis (FEP). Interventions addressing insight are necessary but current treatments have been shown to have limited effectiveness. Thus, a novel intervention, Metacognitive Reflection and Insight Therapy (MERIT), is being studied for its efficacy of improving insight in individuals with schizophrenia spectrum disorders. MERIT is an integrative metacognitive therapy consisting of eight elements to assist clients in improving their ability to form complex ideas about themselves and others and to use this knowledge to respond to psychological problems. The present study is a case illustration of the implementation of MERIT to improve insight in FEP. Clinical outcomes were assessed and results showed that the client improved in both metacognition and insight. With replication, these results suggest that integrative metacognitive psychotherapy may serve as an intervention that improves insight in FEP, which marks an important step toward improved interventions for individuals with psychosis.     

Emotionally Focused Couple Therapy

Abstract

Working with couples who are both survivors of emotional abuse and are currently in an emotionally abusive relationship can be particularly challenging for the clinician. This article focuses on Emotionally Focused Couple Therapy as a recommended practice approach for clients who are caught in emotionally abusive patterns with one another. The article reviews relevant literature on this approach and illustrates the specific interventions applied lo an emotionally abusive couple.     

Emotionally Focused Family Therapy and Play Therapy Techniques

Emotionally Focused Family Therapy provides a framework for understanding children's behaviors in terms of attachment needs of comfort and support. However, when working with young children, play therapy is often developmentally preferred over “talk therapy.” By integrating play therapy techniques within an Emotionally Focused Family Therapy theoretical framework, therapists can help parents understand and meet their child's needs for affection and comfort. This article will discuss how play therapy techniques can be integrated with an Emotionally Focused Family Therapy theoretical framework for work with young children and their families.     

Brief Therapy: Focused Solution Development

This article describes the form of brief therapy developed at the Brief Family Therapy Center. We have chosen a title similar to Weakland, Fisch, Watzlawick, and Bodin's classic paper, "Brief Therapy: Focused Problem Resolution" (20) to emphasize our view that there is a conceptual relationship and a developmental connection between the points of view expressed in the two papers.     

Brief Therapy: Focused Problem Resolution

This article describes a general view of the nature of human problems and their effective resolution and of related specific procedures, growing out of our prior work in family therapy, that have developed during six years of research on rapid problem resolution. With treatment limited to a maximum of ten sessions, we have achieved significant success in about three-fourths of a sample of 97 widely varied cases, and this approach to problems appears to have considerable potential for further development and wider application.     

Metacognitive Reflective and Insight Therapy for a Person Who Gained Maximal Levels of Metacognitive Capacity and Was Able to Terminate Therapy

Schizophrenia often involves a loss of metacognitive capacity, or the ability to form a complex and integrated sense of self and others. Independent of symptoms and impairments in neurocognition, metacognitive deficits are a barrier to the formation and sustenance of goal-directed activities of daily life and ultimately to recovery. Metacognitive reflective and insight therapy (MERIT) is a form of psychotherapy intended to assist patients to recover metacognitive capacity through intensive individual therapy. This paper presents a case illustration of how MERIT assisted a patient with prolonged schizophrenia and significant metacognitive deficits to develop a robustly complex understanding of himself and others and then to use that knowledge to agentically monitor his own experiences and effectively respond to life challenges. The eight elements of MERIT that stimulate and promote metacognitive capacity are presented with an emphasis on how they were implemented when the patient had reached some of the higher levels of metacognitive function.     

The Contribution of Emotionally Focused Couples Therapy

This article describes emotionally focused couple therapy and the contribution of this model to the field of couple therapy. A focus on emotional processing in the present moment, on process factors and on a genuine empathic connection with both clients is at the heart of this model. The creation of new patterns of emotional responses results in the creation of key new interactional responses. EFT is empirically validated on several levels: on the level of treatment outcome, and on the levels of the relational theory in which it is based and key moments and factors in the change process.     

Metacognitive Interpersonal Therapy for Treating Auditory Verbal Hallucinations in First-onset Schizophrenia

Auditory verbal hallucinations (AVHs) are perceptive-like experiences happening without appropriate stimuli, occurring in two thirds of schizophrenia patients, where they often cause emotional suffering and dangerous behaviors, and interfere with social relationships. Patients with schizophrenia involving AVHs can also be drug-resistant or they may discontinue medications. The most well-known psychotherapeutic intervention for voice-hearing is cognitive behavioral therapy (CBT), which focuses on reducing distress by modifying hearers’ beliefs about their voices. We hypothesize that it is possible to reinforce the clinical approach to AVHs by taking into consideration (a) that patients generally hear voices in particular interpersonal contexts where they experience negative emotions; (b) the relationship between AVHs and metacognition, namely the ability to make sense of mental states. On this basis, AVHs can be seen not just as a cause of emotional distress as CBT postulates, but the outcome of difficulties in meta-cognitively making sense of interpersonal exchanges. In this paper, we describe the treatment of a young man at the onset of schizophrenia with pervasive negative AVHs. The patient was treated with metacognitive interpersonal therapy (MIT), aimed to promote the patient’s metacognition. With this aim, in the first part of the treatment, each time AVHs emerged, the patient’s level of arousal was high and his metacognitive ability very low, the therapist treated AVHs helping the patient to understand and cope with the emotional suffering connected with AVHs. At a more advanced stage of therapy, the therapist helped the patient reach the point of understanding the social triggers which, together with the patient’s self-schemas, ignited his auditory hallucinations; this created the conditions for a significant reduction of the pervasiveness of AVHs.     

Collaborative Empiricism in Cognitive Therapy for Psychosis: A Practice Guide

We outline our understanding of collaborative empiricism (CE) as used in cognitive therapy (CT) for psychosis. We discuss how CE can be thought of as a technique for facilitating cognitive change in the service of a client's goals, but also as an expression of respect for client autonomy, recognizing the ethical imperative to empower clients by involving them in decisions about their care. Taking a CE approach is therefore consistent with user-led conceptualizations of recovery, and the related movements of “shared decision-making” and “evidence-based patient choice.” We discuss how CE can aid with engagement, assessment, formulation, and intervention in CT, illustrating this with case material. We focus on how CE can help with distressing intrusive experiences and beliefs, and also consider its role in helping clients achieve wider life goals. Adaptations to CE for working with people with problems with learning, attention, and memory are discussed, as are considerations for working with high conviction and conceptual disorganization.     

Chronic PTSD Treated With Metacognitive Therapy: An Open Trial

This paper reports on an open trial of metacognitive therapy (MCT) for chronic PTSD. MCT does not require imaginal reliving, prolonged exposure, or challenging of thoughts about trauma. It is based on an information-processing model of factors that impede normal and in-built recovery processes. It is targeted at modifying maladaptive styles of worry/rumination and attention so that emotional processing can proceed spontaneously. Eleven out of 13 patients with a mean duration of PTSD of 19.5 months completed treatment. Therapists followed the treatment manual by Wells and Sembi (2004b). Self-report measures of PTSD symptoms, anxiety and depression, and assessor ratings of PTSD were administered at pre- and posttreatment, and at 3- and 6-month follow-up. Treatment appeared to result in large and significant improvements on all measures of PTSD and general measures of anxiety and depression. Statistically significant treatment gains were maintained at 3- and 6-month follow-up. Jacobson's criteria for recovery showed that 90% of patients were recovered at posttreatment. At 6-month follow-up approximately 89% were recovered or reliably improved. Results suggest that MCT could be highly effective and extend evidence of its applicability to more treatment-resistant chronic PTSD cases. Comparisons against other active interventions are now clearly indicated.     

Metacognitive Therapy in Major Depression: An Open Trial of Comorbid Cases

This open trial investigated the transdiagnostic effects of metacognitive therapy (MCT) in patients with severe major depressive disorder and comorbid psychiatric disorder. Ten patients were treated with MCT over 10 sessions and were assessed with measures of depression, anxiety, rumination, and metacognitions at pre- and posttreatment and at 6 months follow-up. None of the patients were diagnosed as depressed at posttreatment, and of the initial 21 total diagnoses at pretreatment only 3 diagnoses remained at postintervention. The effect sizes were large for symptoms of depression, rumination, and worry. At 6 months follow-up standardized recovery criteria on the BDI showed that 70% were recovered, 20% improved, and 10% unchanged. The results indicate that MCT was associated with high rates of transdiagnostic improvement.     

The Efficacy of Behavioral Couples Therapy and Emotionally Focused Therapy for Couple Distress

Twenty treatment outcome studies, 13 of which evaluated behavioral couples therapy (BCT) and seven of which evaluated emotionally focused therapy (EFT) were reviewed, leading to the following conclusions. BCT leads to short and long-term gains for moderate to severe couple distress. In the long term BCT probably leads to no better outcomes than its constituent components—behavioral exchange training and communication and problem solving skills training. Addition of a cognitive therapy component to BCT or the use of a variety of treatment formats does not improve the efficacy of BCT. Integrative couples therapy and insight-oriented marital therapy may be more effective than BCT, but studies supporting this conclusion require replication. EFT leads to short and long-term gains for mild to moderate couple distress. Addition of a cognitive therapy component to EFT does not enhance its efficacy. EFT may be more effective than problem solving therapy and less effective than integrated systemic therapy, but the two studies supporting this conclusion require replication.Michael Byrne, PhD, is a Clinical Psychologist, Midland Health Board, Ireland; Alan Carr, PhD, is Director of the Clinical Psychology Training Programme, Department of Psychology, Arts Building, University College Dublin, Belfield, Dublin 4, Ireland (alan.carr@ucd.ie). Marie Clark, PhD, is Lecturer, Department of Psychology, University of Surrey, United Kingdom.     

Emotionally Focused Couple Therapy with Couples Facing Terminal Illness

Research on effective therapeutic interventions for couples dealing with terminal illness is scant. Changes in daily routine, added responsibilities, role changes, and the grief process are all contributors to the enormous stress and emotional strain felt by these couples. Couples where one partner is terminally ill may experience anger, depression, guilt, and anxiety. The authors propose that emotionally focused couple therapy (EFT), originally developed by Greenberg and Johnson (Emotionally focused therapy for couples, Guilford Press, New York, NY, 1988) may be effective in addressing this distress and in facilitating the grieving and support process in couples dealing with terminal illness. EFT is a systemic, experiential form of therapy that builds upon Bowlby’s (Attachment and loss: Volume I: Attachment, Basic Books, New York, NY, 1969) attachment theory. By exploring the emotional experience of both partners it may be possible to re-structure the couple’s emotional partnership and support the grief process for both partners.     

Homework Use in Cognitive Therapy for Psychosis: A Case Formulation Approach

Based upon empirically supported cognitive-behavioral treatment approaches, this paper aims to outline the use of homework to enhance the therapeutic relationship, patient motivation, and skills for managing delusions, hallucinations, and negative symptoms. The nature and timing of homework is outlined for the different phases of treatment. Frequent barriers that emerge during the setting and reviewing of homework are described, followed by strategies to enhance motivation and homework compliance. The paper concludes with a demonstration of how homework is optimized within a case formulation approach for persistent symptoms of psychosis.     

Adopting Metacognitive Interpersonal Therapy to Treat Narcissistic Personality Disorder with Somatization

Narcissistic personality disorder (NPD) is characterized by an intellectualizing narrative style, poor metacognition, maladaptive interpersonal schemas, a restricted set of states of mind, impaired agency and perfectionism. Metacognitive Interpersonal therapy targets these dysfunctions with a series of formalized procedures aimed at first forming a shared formulation of functioning which patients and therapists can then use to plan change. We describe here the core NPD pathology and illustrate the therapy process of a patient with NPD and a somatization disorder. Implications for treatment of NPD are discussed together with a call for empirical testing of therapies for this severe condition.     

正确认识心理因素在颞颌关节紊乱病中的作用

颞颌关节紊乱病(temporomandibular disorder,TMD)是口腔颌面部常见的疾病之一。TMD病因比较复杂,目前认为是多种因素作用的结果,主要为心理因素、牙合因素等。但是目前对于心理因素在TMD的发生、发展、治疗和转归方面,很多学者尚持有异议。运用系统论中的整体性原则、动态性原则、系统涨落理论、综合性原则和最佳化原则等阐明如何才能获得对心理因素在TMD中的作用的全面认识,并指出重视心理因素在TMD中的作用也是顺应医学模式转变,体现人文关怀的需要。     

正确认识心理因素在颞颌关节紊乱病中的作用

颞颌关节紊乱病(temporomndibular disprder,TMD)是口腔颌面部常见的疾病之一.TMD病因比较复杂,目前认为是多种因素作用的结果,主要为心理因素、牙合因素等.但是目前对于心理因素在TMD的发生、发展、治疗和转归方面,很多学者尚持有异议.运用系统论中的整体性原则、动态性原则、系统涨落理论、综合性原则和最佳化原则等阐明如何才能获得对心理因素在TMD中的作用的全面认识,并指出重视心理因素在TMD中的作用也是顺应医学模式转变,体现人文关怀的需要.     

Cognitive-Behavioral Therapy for Individuals Recovering from a First Episode of Psychosis

Schizophrenia is one of the most devastating psychiatric illnesses. There has been a tremendous worldwide research and clinical effort into early intervention for psychosis. However, despite significant improvement in symptoms after a first episode, there is no corresponding quality improvement in function for many individuals. Thus, increased attention has been given to psychological intervention in particular cognitive behavioral therapy (CBT) with the hope of enhancing functional recovery. Outcome trials of CBT for schizophrenia are promising and other work in CBT suggests this may be a viable psychological intervention for this population. This paper will review the need for a CBT approach after a first episode of psychosis and describe a modular CBT approach for this population. This approach addresses adaptation as well as both functional and symptomatic outcome, an approach which parallels the theoretical shift in CBT that occurred in the last decade.