CBT for Psychosis

Process-orientated Therapies and the Third Wave

Caroline Cupitt, Caroline Cupitt

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781315294834
• Edition: 1
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

Cognitive Behaviour Therapy (CBT) for psychosis is constantly changing and evolving. Recently, in what is sometimes called the 'third wave', therapy has become more concerned with the individual's relationship to their experience, rather than with the content of it. This more process–orientated approach appears to tap into universal psychological processes. The aim is to reduce distress by changing the function of the experience, rather than necessarily the experience itself. Written by some of the leading figures from around the world, CBT for Psychosis: Process-Orientated Therapies and the Third Wave brings the reader the latest developments in the field.

Presented in three parts, CBT for Psychosis first explores theoretical perspectives on recent developments in cognitive behavioural therapies. Part two examines specific therapeutic approaches, including metacognitive training, mindfulness, acceptance and commitment therapy, compassion focused therapy and the method of levels. Finally, part three presents two critical perspectives: the first offering a reflection on the experience of receiving CBT, and the second looking ahead to possible future developments.

Offering a cutting-edge collection of theoretical, therapeutic and critical perspectives, CBT for Psychosis: Process-Orientated Therapies and the Third Wave will be of great interest to clinical and counselling psychologists, both practising and in training, as well as psychiatrists, nurse therapists, occupational therapists and other healthcare professionals working with people experiencing psychosis.

Part 1
Theoretical Perspectives

1
Metacognition in Psychosis

Implications for developing recovery oriented psychotherapies

Paul H. Lysaker and Ilanit Hasson-Ohayon

Psychosis in its many different forms leads to myriad psychological and social challenges that affect not only the lives of persons diagnosed with these conditions, but also the lives of their friends, families, and others in their communities. Our scientific understanding of the course of psychosis, however, has taken an optimistic turn in the last several decades. While it was once firmly asserted that people with psychosis could only hope to have a life in which, at best, they were ‘stable’ and free from acute disturbances in emotion, cognition, and behaviors, careful field research found that many recover (Leonhardt et al., 2017; Silverstein & Bellack, 2008).

In exploring how to characterize recovery, disparate groups have agreed on at least two things. First, recovery can mean different things to different people. Recovery can involve objective phenomena such as symptom remission or the attainment of psychosocial milestones, and subjective experiences including self-appraisals of an acceptable quality of life and the recapturing of a coherent sense of oneself as a valuable person in the world. Second, regardless of what kind of achievements constitute recovery, the person diagnosed with psychosis must feel a sense of ownership of their recovery. This is to say that the person diagnosed with mental illness must be ‘in charge’ of their own recovery. Recovery is thus a matter for the whole person. It is more than a person ‘fixing’ or finding solutions for one or more dilemmas: it requires persons to make their own sense of what they are experiencing in the moment and decide what they want to do about it. Recovery requires that the person be an active agent in that process.

The recognition that recovery is possible and should be the goal of treatment has spurred on efforts to understand the barriers to recovery. After all, if services are to promote recovery, a clear idea of what stands in the way would seem necessary. To date, some of the most widely identified obstacles to recovery from psychosis include anomalous experience such as experiences of permeable boundaries around the self, neurocognitive impairments, isolation, and poverty, as well as trauma history and stigma or stereotyped ideas. In this chapter, we will go beyond this work and look at another set of barriers to recovery and their implications for developing treatments. We are referring here to reduced metacognitive capacities or difficulties forming a sufficiently complex sense of self and others, needed to decide how to respond to the challenges of psychosis and – more broadly – life itself. We will focus on these reduced capacities as they are intimately tied with the potential of persons to be active agents in their recovery. Indeed, helping to restore metacognitive function could help many not only decide what recovery means to them but also to take charge of that process.

To explore the implications of studies on reduced metacognitive capacities for developing psychotherapy, we will first offer a definition and then detail literature supporting the role of metacognition in psychosis. We will explore the implications of this for developing cognitively oriented psychotherapy for psychosis, both in theoretical and technical terms. We will lastly describe recent efforts to operationalize a recovery oriented metacognitive approach to psychotherapy, offering thoughts on how the metacognitive approach can be distinguished from others on the basis of its focus on meaning-making and a person’s sense of self in the human community.

Metacognition

The construct

In this chapter, we use the term ‘metacognition’ to conceptualize and operationalize the processes involved when persons notice and integrate information about themselves and others. However, the term is complex and requires some consideration of its use in different disciplines. By the strictest definition, a metacognition is a cognition about other cognitions. It was first used in education research, to look at learners’ awareness of their own learning (Flavell, 1979). The use of the term metacognition has since been expanded, for example, to deal with self-regulation (Dinsmore et al., 2008), attentional biases (Wells, 2000), and the ability to monitor and correct behavior and one’s own reasoning (Moritz et al., 2007). Taking all of these activities into account, a broader understanding of metacognition has emerged as a larger process in which information is integrated into complex representations of the self and others (Lysaker & Dimaggio, 2014). Here metacognition is seen as a spectrum of activities which, at one end, involves awareness of discrete mental experiences such as specific thoughts, feelings or wishes, and at the other end the integration of those discrete experiences into a larger complex sense of oneself and others. These different ends of the spectrum are also not conceptualized as completely independent activities. The larger senses we form of ourselves are based on awareness of discrete elements of experience, just as we assign meanings to our discrete experience on the basis of our larger sense of ourselves.

This view stresses the representational nature of reflection, emphasizing that the metacognitive process allows us to form a sense of ourselves and others by bringing together an ocean of pieces of information across unique settings over time, rather than being a mirror of reality. It also emphasizes that metacognition is a crucial and not a causal activity. It is intimately tied to meaning-making, which is essential to survival. Metacognition is not an academic activity but is the basis for how one decides what to pursue, with whom, where, and when. Metacognition occurs and evolves intersubjectively. Metacognition requires that selected states and experiences are given meaning and expressed in ways that can be shared and acknowledged between people, in real or imagined interactions (Tomasello et al., 2005; Cortina & Liotti, 2010). Finally, metacognition describes the processes which make available a sense of self and others from moment to moment depending on slightly or grossly changing circumstances.

Different terms in the broad field of psychology have been used to refer to similar phenomena. These terms, which include mentalizing, theory of mind, and social cognition, all share similarities with metacognition. However, the concept of metacognition differs from those terms in several conceptual ways. First, while theory of mind and social cognition are expressly concerned with the correct detection of a thought or feeling, metacognition concerns the integration of those details into a whole; one whose coherence, rather than pure accuracy, is at issue. In contrast to mentalizing, metacognition explicitly distinguishes from one another the formation of integrated ideas of the self, the formation of an integrated sense of other people, and the use of that knowledge. Metacognition also differs from mentalizing in that it understands reduced metacognitive capacities can result from multiple factors, including decrements in neurocognition, social isolation, and stigma. It does not share the view that decrements in reflectivity occur almost exclusively in the context of disturbed attachment and emotion dysregulation (Fonagy et al., 2004). From this view, metacognition may have a bidirectional relationship with both attachment security and emotional regulation.

Operationalization and research in psychosis

One of the first efforts to operationalize the construct of metacognition was offered by Semerari et al. (2003). Influenced by work in attachment (Main, 1991), this group created the Metacognition Assessment Scale (MAS). The MAS offered several advances in the study of metacognition. First, it made the leap of using the term metacognition to describe the processes that go beyond momentary self-awareness and allow emergence of a broader sense of self. Second, it differentiated different forms of metacognition on the basis of their foci: the self (Self-reflectivity); other people (Awareness of the mind of the other); and the use of metacognitive knowledge to respond to emergent psychological and social challenges (Mastery). It also offered an additional subscale concerned with awareness of other, namely Decentration, which concerns the awareness that events can be understood validly from multiple perspectives. This brought to light that our sense of ourselves and others requires the ability to shift back and forth from one’s own perspective to the valid and differing perspectives of others. As originally applied, the MAS was used as a tool to detect the frequency of successful metacognitive acts during psychotherapy.

Applying this conceptualization and operationalization of metacognition to the field of psychosis, Lysaker et al., (2005) created the Metacognition Assessment Scale-Abbreviated (MAS-A). The MAS-A is an adaptation of the MAS and retained the general four-scale structure, though Decentration was designated as an independent scale because of its centrality as an outcome. The MAS-A contains four scales: Self-reflectivity (S), Understanding other’s minds (O), Decentration (D), and Mastery (M). There were major changes from the MAS to the MAS-A. The most substantial change was that MAS-A revised the original MAS items so that each scale was transformed into an ordinal scale. Each item of the S, O, and D scales of the MAS-A represents a mental act which involves a higher level of integration than the item below it. In other words, each ascending item requires a new element to be integrated into one’s self of self, others, and the larger community respectively. For example, the fourth item of the S scale (a sense of self as having distinct cognitive operations and nuanced affective states) produces a more integrated sense of self than the third item level (self as composed only of cognitive operations), but which is less integrated than the fifth item (a sense of self experiencing affective states as changing and thought processes as subjective). For the M scale, each item now represents a response to distress which requires a higher level of metacognitive activity than the one below it. This allowed the MAS-A to assess a person’s maximal capacity and assign a single value separately to the S, O, D, and M scales of the MAS-A.

Research using the Metacognition Assessment Scale-Abbreviated

Research using the MAS-A has suggested it has adequate psychometric properties (Lysaker & Dimaggio, 2014), and that it reflects mental processes which are distinct from social cognition (Lysaker et al., 2013; Hasson-Ohayon et al., 2015). The use of this scale has enabled studies to examine the prevalence and effects of reduced metacognitive capacities in psychosis. This work has found that MAS-A scores of persons given a diagnosis of first episode or prolonged psychosis have more significant reductions in metacognitive capacities than persons with prolonged non-psychiatric medical conditions or substance abuse disorders (Lysaker, Leonhardt et al., 2014; Lysaker, Vohs et al., 2014), minor anxiety and affective disorders (WeiMing et al., 2015), and community members without mental health conditions (Hasson-Ohayon et al., 2015; Popolo et al., 2017). Reductions in metacognitive capacities have also been noted in other mental health conditions, including depression (Ladegaard, et al., 2014), post-traumatic stress disorder (Lysaker, Dimaggio et al., 2015), borderline personality disorder (Lysaker et al., in press), and bipolar disorder (Popolo et al., 2017). Metacognition as a process of integration has been found to be more closely related to function than specific dysfunctional metacognitive beliefs (Popolo et al., 2017).

Research has reported that reductions in metacognitive capacities negatively affect functional competence (Lysaker, McCormick et al., 2011), subjective recovery (Kukla et al., 2013), therapeutic alliance (Davis et al., 2011), stigma (Nabors et al., 2014), physical activity levels (Snethen et al., 2014), reasoning bias (Buck et al., 2012), hedonic response to life (Buck et al., 2014), clinical insight (Lysaker et al., 2005) and intrinsic motivation (Luther et al., 2016a) in psychosis, regardless of levels of symptom severity. Reductions in metacognitive capacities have also been found to predict future levels of vocational function (Lysaker, Dimaggio et al., 2010), negative symptoms (Hamm et al., 2012; Lysaker et al., 2015; McLeod et al., 2014) and intrinsic motivation (Luther et al., 2016b), regardless of baseline functioning. A recent meta-analysis (Arnon-Ribenfeld et al., in press) affirmed the existence of associations between reductions in metacognitive capacities with symptomatic and psychosocial functioning in persons diagnosed with schizophrenia.

Of note, in a broader historical framework, it has been suggested that these findings linking disruptions in function with disturbances in metacognition bear a striking similarity to some of the original conceptualization of the concept of schizophrenia. In particular, parallels have been drawn between this metacognitive model and Bleuler’s (1950) contention that the disruption in goal directed behavior in what he termed schizophrenia, was largely the result of disturbances in associative process or the ability to link ideas together via associative threads (Lysaker & Klion, 2017). Thus, the self as an agent is related to the ability to reflect upon oneself and others and use these reflections in order to facilitate recovery.

Four implications for developing forms of psychotherapy for psychosis

The treatment target is a capacity which can improve over time

Given that reductions in metacognitive capacities represent an immediate barrier to recovery, psychotherapies that successfully enhance metacognition and opportunities for healthier function and recovery are needed. The metacognitive research paradigm, noted above, offers important directions for how to conceptualize the interventions, processes, and outcome of any developing psychotherapy. To begin, it tells us that metacognition is a continuous, not a categorical variable; metacognition is a capacity which can wax and wane. As such, this offers what we think is the first major implication for treatment: namely treatment should not approach metacognition as something someone has or does not have. Instead treatment should approach metacognition as something a person possesses to a varying degree and something they can acquire more of over time. In addition, metacognition is perceived as a multi-dimensional phenomenon that includes the four related dimensions presented above. As such, one can have high self-reflection abilities but low ability to understand others’ minds, or vice versa.

Importantly, since metacognition here is understood as an ability, rather than a knowledge set, to enhance metacognition treatment would need to offer persons opportunities to think about themselves, others, and about the use of that knowledge. By having opportunities which are repeated over a period of time, persons might become more able to think about themselves and others and use that knowledge in more complex and flexible ways. Using the metaphor of physical therapy, psychotherapy may most effectively impact metacognition when it offers patients the opportunity to practice acts that are difficult for them, with the result that incrementally they become more able to perform those acts in the flow of life.

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Table of contents

• Cover
• Title
• Copyright
• CONTENTS
• List of illustrations
• Notes on contributors
• Acknowledgements
• Introduction
• PART 1 Theoretical perspectives
• PART 2 Specific therapeutic approaches
• PART 3 Critical perspectives
• Index