The Recovery of the Self in Psychosis

Contributions from Metacognitive and Mentalization Based Oriented Psychotherapy

Ilanit Hasson-Ohayon, Paul H. Lysaker

• Publisher: Routledge
• Year: 2021
• ISBN:
  9780429943164
• Edition: 1
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

The Recovery of the Self in Psychosis details specific therapeutic approaches as well as considers how treatments can be individually tailored and adapted to help persons whose mental health challenges may be either mild or more severe. By focusing on basic elements of the experiences of persons diagnosed with psychosis and exploring the broader meanings these experiences have, each of these treatments offers distinctive ways to help persons define and manage their own recovery. The book includes measurable therapeutic processes, an empirically supported conceptual basis for understanding disturbances in self-experience and rich descriptions of the recovery process.

The Recovery of the Self in Psychosis moves beyond approaches which dictate what health is to persons with psychosis through education. It will be essential reading for all clinical psychologists and psychotherapists working with people diagnosed with psychosis.

1
THE ROLE OF METACOGNITION AND MENTALIZATION IN THE RECOVERY OF THE SELF

Introduction and overview

Ilanit Hasson-Ohayon and Paul H. Lysaker

Abstract: Emerging evidence from studies on the subjective experience of recovery from psychosis indicates that mental health services need to move beyond seeking to reduce symptoms or promote skill acquisition. Wellness, as it is increasingly defined in terms of mental health, recognizes that services need to take into account the sense people make of the challenges they face and any resultant decisions about how they should best respond to these. Services are thus needed to support sense-making, including the ability to reflect upon and form an evolving and adaptive sense of oneself and one’s place in the larger human community. In line with this, several different approaches to recovery-oriented psychotherapy and psychosocial rehabilitation are currently being developed for persons diagnosed with psychosis. Many of these approaches explicitly, or implicitly, use the terms metacognition, or mentalization, to describe the processes they target, in order to enable persons to form more integrated and diverse senses of self and others which would promote recovery. In this chapter we offer an introduction to an edited volume which not only presents a range of these kinds of therapies but also illustrates their potential to be useful in creating change and enhancing recovery for persons with a range of very different goals, abilities and challenges. To prepare the reader, we offer a description of the nature and evolution of the terms metacognition and mentalization, and discuss their theoretical links with health.

The experience of psychosis cannot be reduced to any one set of symptoms, skill deficits, developmental experiences or even specific social or political challenges (Lysaker & Lysaker, 2010). Psychosis involves alterations to self-experience in which the previously held sense of self, and its trajectory over one’s life, may be degraded or weakened, leaving a person less able to form an integrated idea of their past, emerging challenges or how to act as an agent in the world and to respond to these challenges (Lysaker & Klion, 2017). As suggested over a century ago by William James (1890), human experience is more than the experience of the world. Human beings also have self-experience or the experience of themselves experiencing the world. Self-experience is fundamentally a different kind of experience in contrast to an experience of an object we encounter. When human beings experience themselves experiencing the world, this is the experience of responding to the world and making interpretations and actions which are the basis for managing what is unfolding in the flow of life. It is also the basis for the experience of ourselves as having purposes, our relative position in the social world and self-complexity (Lysaker & Lysaker, 2017). In reference then to alterations to the sense of self in psychosis we are therefore concerned with the basic foundations of consciousness and subjectivity through which people continually experience their daily life (Moe & Docherty, 2013).

Challenges to the sense of self include disturbances in these basic foundations and have been documented in research on self-experience and psychosis. For example, studies have shown that persons with psychosis can have a degraded sense of self-clarity (Hasson-Ohayon et al., 2014) and reduced abilities to describe their own emotions (Fogley, Warman, & Lysaker, 2014). Based on this perspective, recovery from psychosis would seem for many to involve the reversal or amelioration of alterations to sense of self. The need to consider sense of self as a key aspect of recovery has important clinical implications. Among these is the likelihood that treatments that are primarily concerned with symptom remission and skill attainment such as cognitive behavioural therapy (CBT; e.g. Hagen, Turkington, Berge, & Gråwe, 2013) or others focused on the resolution of conflicts rooted in earlier experiences through psychoanalytical approaches (e.g. Robbins, 1993), may not be sufficiently well equipped to deal with these aspects of recovery. To address alterations to self-experience, interventions which involve processes and methods that support persons in recapturing the ability to experience an integrated sense of themselves and others within the flow of life are needed (Lysaker, Glynn, Wilkness, & Silverstein, 2010).

Spurred by reflections such as these, efforts have been underway for over a decade to develop psychosocial services, including group and individual psychotherapies, that can address alterations to self-experience among persons diagnosed with psychosis. While these therapies differ along many dimensions, they are alike in their goals to address clients as unique subjects, to promote sense-making of challenges related to a diagnosis of psychosis and other experiences of the self, and to enhance agency (Lysaker & Hasson-Ohayon, 2018). Each of these therapies also aspires to be broad enough to apply to persons with differing, needs, goals, abilities and challenges.

In this book, we explore one group of therapies focused on these issues. This set of therapies includes metacognitively and mentalization-oriented therapies which are primarily focused on supporting recovery by enhancing reflectivity in an inter-subjective framework. To better establish the interconnections among these psychotherapies, we will begin this volume with a review of updated conceptualizations of recovery, metacognition, mentalization and intersubjectivity. This review of the literature is followed by a description of the chapters included in the book. Of note, given the natural space limitations that come with any printed volume, we have restricted our focus to treatments that have a significant intersubjective component. We thus have not been able to include a range of recovery-oriented treatments whose mechanisms may nevertheless be similar to those described. These include Metacognitive Training (Moritz et al., 2014), Open Dialogue (Bergström et al., 2018), as well as clubhouse-based approaches (Tanaka, Davidson, & Craig, 2018). We therefore wish to acknowledge at the outset the need for future work to better elucidate the larger connections that exist within recovery-based care.

Psychosis and the self: barriers to health and achieving recovery

Since the end of the 19th and beginning of the 20th centuries, the loss of cohesive self-experience has been thought to play a central role in the interruption of a life that is often experienced in psychosis. Kraepelin (1896), Bleuler (1911) and Jaspers (1923) all referred to alterations in consciousness as an underlying feature of psychosis. Since then, similar observations have been made in the psychoanalytic literature (e.g. Searles, 1965), existential literature (e.g. Laing, 1960), phenomenological psychiatry (e.g. Stanghellini, 2000; Parnas & Handest, 2003), first-person accounts (e.g. Andresen, Oades, & Caputi, 2003) and empirical research (e.g. Hasson-Ohayon et al., 2014; Hasson-Ohayon, Goldzweig, Lavi-Rotenberg, Luther, & Lysaker, 2018; Lysaker, Dimaggio et al., 2018). Synthesizing this work, it has been suggested that for many persons diagnosed with psychosis, the ability to form integrated ideas about oneself and others is compromised. This may lead to difficulties in experiencing oneself as an agent who can reflect upon and respond to challenges and opportunities as they emerge in the world (Lysaker et al., 2020). One implication of this work is that recovery for many might involve a recapturing of the ability to form and use a cohesive and integrated sense of self and others as life unfolds. In other words, if a primary challenge to recovery is the loss of a previously held sense of self then recovery is likely to include the recapturing of that sense of self.

Of note, the construct of recovery has evolved considerably over the last few decades. The idea of recovery as involving social and personally meaningful changes first emerged in contrast to earlier models of psychosis which stressed that persons diagnosed with these conditions would most often experience deteriorating psychological and social function over time (c.f. Leonhardt et al., 2017; Roe, Mashiach-Eizenberg, & Lysaker, 2011; Silverstein & Bellack, 2008). Following longitudinal research demonstrating that the majority of persons diagnosed with serious mental illnesses are able to achieve a fully meaningful quality of life over time (Harding, Brooks, Ashikaga, Strauss, & Breier, 1987), and the survivors’ movement that emphasized human rights and personal choices (Chamber-lin, 1978), it was proposed that people with a diagnosis of psychosis can achieve, over time, a personally and socially meaningful life (c.f. Leonhardt et al., 2017). Further, the resolution of these challenges has been recognized to involve a broad multi-dimensional set of processes and outcomes (Leonhardt et al., 2017; van Weeghel, van Zelst, Boertien, & Hasson-Ohayon, 2019). Specifically, recovery has been suggested to involve a set of complementary objective and subjective aspects (Roe et al., 2011), which correspond to evaluations made by others and by the person respectively. Examples of objective aspects of recovery include symptom remission and the achievement of measurable behavioral milestones (Leonhardt et al., 2017). By contrast, subjective aspects of recovery are those that are directly connected to persons’ experiences of themselves. As discussed by Anthony (1991), these are related to: “a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with the limitations caused by illness” (p. 527).

Metacognition and mentalization as treatment approaches that could promote the recovery of a sense of self

As the experience of oneself experiencing the world, including one’s purposes and place in the world, is by definition fundamentally subjective, the recapture of a subjective and reflective sense of self would necessarily be amongst the most subjective of all aspects of recovery and one of the most daunting to describe systematically. In an attempt to tackle the question of how psychosocial interventions might approach the issue of alterations to self-experience, it has been proposed that recovery-oriented treatments might address the processes which enable persons to form integrated and evolving ideas of themselves and others.

Metacognition and mentalization are two constructs which have been proposed to capture, in part, what allows human beings to have an integrated sense of themselves and others. Both constructs, along with the constructs of theory of mind and social cognition, are used to describe the processes which allow persons to think about one another (Pinkham et al., 2014). However, while social cognition abilities are focused on the capacity to make a correct judgement or inference about someone’s emotional state or intentions, metacognition and mentalization refer to how well persons are able to integrate information into a larger sense of oneself and others (Fonagy, Gergely, & Jurist, 2018; Lysaker & Dimaggio, 2014).

The term metacognition was originally developed by Flavell (1979) on the basis of previous work in developmental and educational psychology (e.g. Vygotsky, 1931), to describe the myriad activities which allow persons to be aware of and reflect on their thoughts and experiences (Moritz & Lysaker, 2018). Notably, the current book adopts an integrative model of metacognition (Lysaker & Klion, 2017). This model attempts to further synthesize developments in the study of metacognition from studies of human development, cognitive psychology and constructivist psychology, as well as from general psychopathology, in order to describe the processes that enable persons to have available to them a sense of self and others. Importantly, these senses of self and others, which people can access and reflect on and which are the basis for action, are explicitly not perceptions of singular objects. The sense of self and others, which metacognition makes available, are formed within particular contexts by the integration of a broad range of embodied, cognitive, emotional and interpersonal experiences (Lysaker, Dimaggio et al., 2018). Moving away from metacognition as purely a cognitive phenomenon means that metacognition involves not only effortful reflection, but also an ongoing set of automatic activities. That is, people do not have a sense of themselves only when they effortfully summon or create one. Often our senses of who we are, and who others are, are simply present for us to think about.

To quantify metacognition, the integrative model proposes that it is a spectrum of experiences which range from the awareness of discrete and highly specific mental experiences (e.g. specific thoughts, emotions, or wishes) to a broader sense of the self and others that results from the synthesis of those discrete experiences (Hamm et al., 2012; Lysaker & Dimaggio, 2014; Lysaker & Hasson-Ohayon, 2014). In this model, both discrete and synthetic metacognitive acts are thought to influence one another. Our larger sense of self and other requires individual pieces of experience which can be later assembled. These individual pieces of experience are given meaning according to their context that is related to a larger sense of ourselves and others.

This conceptualization of metacognition has allowed it to be measurable as a progression of steps towards integration. To date most of this research has been carried out using the Metacognition Assessment Scale-Abbreviated (MAS-A; Lysaker et al., 2005), measuring metacognition as a multi-dimensional construct which is considered to be trait-like. This coding system was developed on the basis of Semerari et al.’s (2003) Metacognition Assessment Scale (MAS), a scale originally designed to detect changes within psychotherapy for adults with personality disorders. Following the MAS, the MAS-A divides metacognitive activities into four categories: 1. self-reflectivity, which refers to the comprehension of one’s own mental states; 2. understanding others’ minds, which refers to the comprehension of others’ mental states; 3. decentration, which refers to the ability to take a non-egocentric view of the mind of others and recognize that others’ mental states are influenced by a range of factors; and 4. Mastery, which refers to the ability to use complex metacognitive knowledge in order to cope with psychological problems. Unlike the MAS, the MAS-A considers the items of each scale as reflecting increasingly complex metacognitive acts, each calling for a greater level of integration than those before it. In this sense, each item of any of the four MAS-A scales is thought to reflect an ability that must be present at a basic level before the activities on the next level can be successfully carried out. The score for each subscale allows researchers to rate metacognitive functioning along a spectrum ranging from highly fragmented to highly integrated (Lysaker & Klion, 2017).

Similar to the concept of metacognition, ...

Table of contents

• Cover
• Half Title
• Series Page
• Title Page
• Copyright Page
• Contents
• List of contributors
• 1 The role of metacognition and mentalization in the recovery of the self: introduction and overview
• 2 A mentalization-based treatment framework to support the recovery of the self in emerging psychosis during adolescence
• 3 Adapting Metacognitive Reflection and Insight Therapy for Early Psychosis (MERIT-EP): a focus on insight and recovery of the self
• 4 The process of recovery of sense of self in the face of persecutory delusions and hostility
• 5 The recovery of the self in adults with delusions: a mentalization-based psychotherapy
• 6 Transference and countertransference in the recovery of self in metacognitively-oriented therapies for psychosis
• 7 The potential for reduction or discontinuation of antipsychotic medication with the use of Metacognitive Reflection and Insight Therapy (MERIT)
• 8 Narrative Enhancement Cognitive Therapy (NECT): the recovery of the self from internalized stigma
• 9 The recovery of sense of self while coping with negative symptoms
• 10 The recovery of the self through Therapeutic Alliance Focused Group Therapy
• 11 Trauma and meaning-making in the recovery of the self: implications for Metacognitive Reflection and Insight Therapy (MERIT)
• 12 A common journey: the recovery of the self in psychosis through therapeutic interactions
• 13 The recovery of the self in psychosis: a concluding unscientific postscript
• Index