Metacognitive and Insight Therapy (MERIT) for Persons With Schizophrenia: Assessment of Session by Session Progress and Outcome.
Phase: NA
Conditions: Diagnosis of Schizophrenia Spectrum Disorders
Sponsor: Bar-Ilan University, Israel

July 2023
 
 
 
 
Metacognitive and Insight Therapy for Persons With Schizophrenia  
(RCT MERIT) 
Clinicaltrial. gov ID NCT03427580 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

July 2023
 
Background: Updated approaches to psychotherapy with people with schizophrenia emphasis 
reflective processes as both mechanism of change toward recovery, as well as desirable 
outcome essential to the experience of the self in a coherent integrative manner (Hasson-
Ohayon & Lysaker, 2021). This emphasis is based on extensive research showing that people 
with schizophrenia  often show challenges in experiencing themselves in a coherent 
meaningful way as agents in the world that are connected to others (e.g. Lysaker, Hamm, 
Bethany & Lysaker 2019; McCarthy-Jones et al., 2013). Although the need to address these 
deficits of the self-experience in treatment was already argued more than a century ago and 
has a long history, (Kraepelin, 1896; Bleuler, 1911; Jaspers, 1923), it is only recently that 
evidenced based and theory driven reflective approaches to psychotherapy with people with 
schizophrenia have emerged.  One of these approaches, Metacognition Reflection and Insight 
Therapy (MERIT, Lysaker & Klion, 2017)  have been applied in different psychiatric settings and 
was tested for its effectiveness. Randomized controlled trials (Vohs et al., 2018, de Jong et al., 
2019), open trials (Bargenquast & Schweitzer, 2014; de Jong et al., 2016), session by session 
assessment of change (Lavi-Rotenberg et al., 2020), qualitative studies (de Jong et al., 2019; 
Lysaker et al., 2015) and a series of case studies (e.g. Cohen-Chazani et al., 2021, Arnon-
Ribenfeld et al., 2018; Hasson-Ohayon et al., 2017; Igra et al., 2020) support its effectiveness 
in improving different dimension of metacognition and selfexperience such as mastery and 
self-reflection. Interestingly, in few case studies reliable change index showed also 
improvement in general symptoms of distress (Arnon-Ribenfeld et al., 2018; Igra et al., 2020) 
as well as in psychotic symptoms (Cohen-Chazani et al., 2021) and descriptive reports showed 
improvement  in negative symptoms and functioning (Hillis et al., 2015; van Donkersgoed et 
al., 2016).   However, no systematic evaluation of change in symptoms of psychosis was carried 
out and it is not clear whether MERIT contribute to parallel improvement in both 
metacognition and symptoms.  In an attempt to broaden the literature on the effectiveness of 
MERIT the current study assesses changes in both metacognitive abilities as well as in 

July 2023
 
symptoms among people diagnosed with schizophrenia. Evidently, associations between 
metacognition and symptoms were subject to previous studies that showed better 
metacognition is related to decreased level of symptoms (e.g. Hasson-Ohayon et al., 2018; 
Lysaker et al., 2005; Nicolo et al., 2012) and meta-analysis further support this (Arnon-
Ribenfeld et al., 2017). Of note, it was suggested that this association is mediated by 
interpersonal functioning (Brune, 2006; Salvatore et al., 2008) so that metacognition leads to 
better social relationships and this results in less withdraw, distress and additional symptoms. 
Thus, it might be that during MERIT, improvement in metacognition will be accompanied with 
improvement in symptoms, interpersonal functioning and general quality of life.  This research 
question, addressed in the current study, was examined in the unique context of covid-19 
pandemic. Half time of the duration of the current reported trial took place under conditions 
of quarantine and gathering limitations. As previously reported (Hasson-Ohayon & Lysaker, 
2021) adaption to online meetings were done when possible and content in therapy naturally 
included coping with the pandemic and related stress. Thus, the current study also seeks to 
explore whether under these unique circumstances that included both high pandemic related 
distress of patients as well as often online meetings, MERIT will result in improvement in 
metacognition, symptoms and quality of life for people diagnosed with schizophrenia. A 
delayed randomized controlled trial was applied to answer this question, in an outpatient 
university community clinic.   
Method: The study used a delayed randomized controlled trial design and session-bysession 
assessment to examine the therapeutic benefits of 24 sessions of MERIT delivered in a 
community clinic at Bar-Ilan University (Clinicaltrial.gov ID NCT03427580).  The clinical trial 
was advertised in rehabilitation centers, mental health centers and in relevant internet sites 
and Facebook groups. Participants approached the clinic voluntarily, seeking therapy due to 
psychological challenges. Participants were offered 24 sessions of MERIT in reduced fee, as 
part of the research trial. All participants were screened on the telephone by clinical or 

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rehabilitation psychologists. Participants that aligned with inclusion criteria were invited to an 
intake meeting. They signed an informed consent form describing the study design and 
purposes, and completed baseline assessment. After completing the intake participants were 
randomized for immediate or delayed intervention. Participants in the immediate intervention 
received 24 weekly sessions of MERIT and were assessed after treatment. Participants in the 
delayed intervention group had a six month wait period and were assessed before and after 
waiting, then they were offered 24 sessions of MERIT and were assessed after treatment.    
Statistical analysis: In order to examine the therapeutic benefits of MERIT, the outcome 
measures (metacognition – MAS-A) will be analyzed by means of repeated measures of 
multivariate analysis of variance (MANOVA). We will use group (MERIT\ Control) as between 
subject factor and time (T1\T2) as within subjects' factor. In addition, reliable change index 
(RCI; Jacobson & Traux, 1992) of the outcome measures will be computed for each participant  
that completed MERIT (from both groups).