Metacognitive Reflection and Insight Therapy (MERIT) is a model of psychotherapy based upon research suggesting that persons who experience psychosis have problems forming a sufficiently integrated sense of self and others. In turn, these difficulties in one’s ability to reflect on oneself and others lead to difficulties sustaining goal-directed behavior. An integrated sense of self and others is created when one is able to combine different pieces of information into a complex and coherent whole and reflect upon that understanding. The processes that allow us to form these integrated ideas are referred to as metacognition and significant impairments in this ability are called metacognitive deficits.
MERIT is provided at least once a week with sessions lasting 30 to 50 minutes depending upon patient need and preference. It is an integrative approach driven by the overarching theory that metacognitive deficits are a central barrier to recovery from severe mental illness. As an integrative therapy, it supports the use of a variety of techniques and interventions in the service of promoting the incorporation of information and experience into sufficiently complex and coherent understandings of self and others. MERIT is intended to allow therapists from a variety of theoretical orientations to use existing skills in new and creative ways.
For MERIT to be effectively carried out, therapists should be familiar and comfortable with several foundational assumptions:
- Recovery from severe mental illness is possible.
- Patients are active agents in their own recovery in all phases of illness.
- The role of the therapist is one of an equal participant or consultant in the thinking process and not one who is prescriptive or holds all the answers.
- The experiences of persons with psychosis can be understood by those persons and by others who try to understand them.
- Greater levels of awareness may lead to the emergence of emotional distress or pain for many with psychosis.
- Stigma can be found in all corners of society, has a profound negative impact on the lives of persons with mental disorders, and could be a barrier to the development of metacognitive capacity.
- Metacognition is the ability to form integrated ideas about one’s self and others and to use that capacity knowledge to respond to life challenges.
- Metacognitive deficits observed in schizophrenia and other severe mental illnesses interfere with the ability to make sense of one’s life and to chart a course to recovery.
- MERIT’s intent is to help clients to form more integrated ideas about themselves and others with the goal of increasing their ability to respond more adaptively to social and psychological challenges and ultimately live their lives in a richer and more fashion.
MERIT is intended to help patients to develop their metacognitive capacity by repeatedly practicing metacognitive acts by having therapists think with patients about their sense of themselves and others and ultimately using that knowledge to respond to life’s challenges.
MERIT involves eight related activities or elements, each of which provides a different opportunity for patients to reflect about their sense of self and others.
- Agenda involves attending to the patient’s immediate wishes and desires.
- Dialogue involves therapists’ sharing their thoughts about patients’ mental activities and behaviors without overriding patients’ agendas.
- Narrative focus involves attending to and reflecting with patients’ about their sense of themselves and others within the flow of life.
- Psychological problem involves attending to patients’ sense of the psychological and social challenges they face.
- Reflection upon interpersonal process involves attending to the patients’ sense of how they are relating to the therapist
- Perceptions of change involves the therapist attending to the patients’ sense of what they are experiencing as it is happening within the session.
In addition to each of these elements, MERIT also asks therapists to assess the patients’ maximal metacognitive capacity within the session and to work with patients at their current maximal metacognitive level to:
- Optimally stimulate reflections about self and others which involves the therapist ensuring that patients are stimulated to think about themselves and others as their current maximal capacity for the metacognitive activity.
- Optimally stimulate metacognitive mastery which involves therapists attending to the patient’s use of sense of self and others to respond to psychological and social challenges.
Element 1: Agenda involves attending to the patient’s immediate wishes and desires. This discussion is referred to as an agenda and typically includes the wishes, hopes, desires, plans, and purposes that a patient brings to each session. MERIT follows the fundamental assertion that human behavior is purposeful and that patients are all seeking something when they come to a session. As a result, this element asks the therapist to be both continuously attuned to what patients may be seeking and to think with patients about this. This stance requires that therapists perceive and respond to patients as actively seeking something and not as someone who needs to be directed or corrected. Patients can have multiple complementary as well as contradictory agendas as well as be more or less aware of those agendas in the moment.
Some examples of patient agendas include:
- To feel less anxious
- To establish something is not their fault
- To make the therapist feel confused
- To convince the therapist to agree with their estimation of another person
- To feel safe
- To feel connected to someone
- To be rejected by the therapist
- To be admired by the therapist
- To please the therapist
- To seek permission to give up
- To decide how to respond to a loss
- To avoid a drug relapse
Goal: Patient will develop a greater awareness of their wishes and intentions.
Facilitated by: Ongoing and evolving understanding of the patient's agenda
Impeded by: Taking verbalizations at face value and ignoring the subtleties and hints inherent during session communication.
Element 2: Dialogue involves therapists’ sharing their thoughts about patients’ mental activities and behaviors without overriding patients’ agendas. While the Agenda element offers patients the chance to reflect upon what they are seeking, here patients are offered a chance to reflect about what they think about the therapist’s presence, behavior, and thoughts about them.
Examples may include the therapist sharing that:
- The patient is smiling while describing things that are generally frightening
- The therapist is confused by what the patient is saying
- The therapist notices the patient is wearing dark glasses or an odd orange hat
- The therapist is hearing things from the patient that makes him or her feel anxious
- The therapist feels as if they say the wrong thing they will anger the patient
- The patient has not spoken of the crisis that was the subject of the last three sessions
- The subject has not arisen that the patient failed to attend the last two sessions without cancelling
Goal: Patients will develop a greater awareness of how they are reacting to the therapist.
Facilitated by: Therapists sharing their own thoughts about the patient and reflecting upon them together.
Impeded by: Therapists taking a hierarchical, education-based, fearful, or timid stance.
Element 3: Narrative Focus involves attending to and reflecting with patients’ about their sense of themselves and others within the flow of life. MERIT seeks to forge a mutual understanding with patients by viewing their experience as comprehendible and available for understanding within the events and contacts with others that are unique to their lives.
Patients are expected to vary in their abilities to produce coherent and lengthy narratives. Some will begin only able to produce fragments of what will later become more coherent and lengthy narratives. Therapists should promote discussion of issues in terms of sequences of events involving specific people and places that have personal relevance regardless of length and regardless of whether it has been discussed before. Often, the more a patient reviews a particular memory or life event, more details emerge that contribute to a deeper and more nuanced understanding. When patients make an abstract claim about themselves, such as they have a certain personality trait, therapists should use this as an opportunity for joint reflection about those claims and inquire about unique details that were specific to that event such as who was present, what was happening, and the antecedents and consequences of the event.
Goal: Patients will develop a greater awareness of their own mental states (e.g., thoughts or feelings) and changes in them within the flow of life
Facilitated by: Therapists eliciting and exploring narrative episodes
Impeded by: Therapists not seeking sufficient details or discussing experiences abstractly
Element 4: Psychological Problem involves attending to patients’ sense of the psychological and social challenges they face. Here, the therapist and patient should be thinking together about the difficulties that emerge as the dyad thinks together.
Some patients may have multiple and perhaps contradictory problems. They may be unable to articulate these difficulties or struggle to perceive a problem within a matter of fact account of their lives. This element does not necessitate agreement about the “correct” or “true” problem but simply conjoint reflection upon it.
Additionally, the focus should be upon psychological problems. For instance, symptoms such as hallucinations or implausible beliefs may not necessarily be valuable areas for exploration. However, affective states such as feelings of loneliness resulting from being shunned as a “voice hearer” or experiencing feelings of terror resulting from beliefs that one is being persecuted are much more likely to be.
Goal: Patients will develop a greater awareness of themselves as confronted with specific dilemmas, challenges, and forms of emotional distress
Facilitated by: Therapists identifying personal and meaningful psychological struggles using common, understandable language
Impeded by: Therapists focusing on preconceived problems or using non-specific symptom focused language
Element 5: Reflection Upon Interpersonal Process involves attending to the patients’ sense of how they are relating to the therapist. Within each session, patients should be encouraged to reflect not just upon the therapists’ thoughts, as in the Dialogue element, but also on the larger interpersonal processes that are taking place in sessions between the therapist and client, especially when they impact patients’ reflective process.
This requires therapists to create or seize on opportunities for patients to reflect on their own thinking about the therapy relationship, either in terms of what they are currently experiencing or are seeking to experience. Therapists should encourage patients to speak about difficult issues regarding their relationship and welcome disclosure of both negative and positive feelings. This element does not necessitate a “correct” description of the relationship but rather mutual reflection on the part of patients and therapists.
Goal: Patients will develop greater awareness of how they are relating to the therapist
Facilitated by: Therapists providing opportunities to think about how patients perceive and relate to the therapist
Impeded by: Therapists failing to try to develop a frank and evolving understanding of how they are experienced by patients
Element 6: Perceptions of Change involves the therapist attending to the patients’ sense of what they are experiencing as it is happening within the session. Reflection should be encouraged in every session about progress or changes resulting from the session.
Patient reflection on progress and change (within the context of either a single or multiple sessions) should be invited. Content may include eliciting reflections about specific outcomes, impact of treatment upon life events, or coping with subjective feelings of distress or confusion.
Goal: Patients will develop greater awareness of their own experience of progress and lack of progress in therapy
Facilitated by: Therapists eliciting how the patient thinks sessions are progressing
Impeded by: Therapists assuming what progress has or has not been accomplished or being unaware that unexpected gain could be discerned
Element 7: Optimal Stimulation of Reflections about Self and Others involves the therapist ensuring that patients are stimulated to think about themselves and others at a level consistent with their current capacity for the metacognitive activity. An intervention is said to match the patients’ metacognitive capacity when it calls for the patent engage in a metacognitive act that does not exceed their capacity as determined by the Metacognition Assessment Scale – Abbreviated. (The MAS-A and training in its use are available from the MERIT Institute.)
Therapists should assess patients’ metacognitive capacities on an ongoing basis. As metacognitive capacities are observed to change within and between sessions, the type of of interventions should change accordingly. Offering interventions that call for metacognitive acts that exceed current abilities are likely to be frustrating and result in failure experiences, possibly exacerbating symptoms.
Goal: Patients will develop an increasingly more integrated sense of self and others
Facilitated by: Therapists using interventions that are appropriate to the patient’s current metacognitive capacity
Impeded by: Therapists failure to adjust interventions to the patient’s capacity in the moment for metacognitive acts pertaining to the self or others
Element 8: Optimal Stimulation of Metacognitive Mastery involves therapists attending to the patient’s use of sense of self and others to respond to psychological and social challenges. As the capacity for reflection about the self and other increases, patients are expected to not only increasingly use the knowledge but to also use it in increasingly sophisticated manner. Stimulating patients to think at levels beyond their current capacities is unhelpful and may even be harmful. As with Optimal Stimulation of Reflections About Self and Others, assessment of Mastery should be conducted within sessions by use of the MAS-A. (The MAS-A and training in its use are available from the MERIT Institute).
Goal: Patients will develop an increasing ability to utilize metacognitive knowledge when responding to psychological and social challenges
Facilitated by: Therapists using interventions that are appropriate to the patients’ current metacognitive capacity
Impeded by: Therapists failing to adjust interventions to patients’ capacity for metacognitive mastery