Metacognition in psychosis: a renewed path to understanding of core disturbances and recovery‐oriented treatment
Authors: Paul H. Lysaker, Ilanit Hasson‐Ohayon
Journal: World Psychiatry (2021)

Consistent with early definitions of schizophrenia as marked by a fragmentation of thought, emotion and desire1, psychosis is currently understood as involving deep disturbances in the sense that persons have of themselves and their connection with the world2. Though endemic across psychosis3, it has remained unclear how to operationalize and measure the processes which underlie and sustain these alterations in self-experience. One challenge for empirical research is that the sense anyone has of him/herself, given its intimacy, immediacy and elusiveness, is not easily measured. Validated assessments, for example, of the oddness of thinking, thought disorder, reasoning biases, or the inaccuracy of judgments do not capture how people amidst psychosis experience their purposes, possibilities, and life trajectories differently4. Nevertheless, it is possible to evaluate processes that underlie the subjective disturbances that characterize psychosis. The sense anyone has of him/herself is enabled by the integration of experience. A sense of oneself in the world is made possible by the active synthesis of discrete experiences into a larger sense in which the relationship of those discrete experiences lends meaning to one another2. One line of research has proposed that metacognition is a process whose disruption could result in alterations of self-experience in psychosis2. Metacognition, across disciplines, refers to the awareness of one's own thoughts and behaviors, and the ability to therefore monitor and alter behavior5. Applied to subjective experience in psychosis, an integrative model has conceptualized metacognition as a spectrum of activities that range from awareness of discrete cognitive, emotional and embodied experiences to the synthesis of those experiences into a broader awareness of the self, others and one's place in the community4. Metacognition, in this integrated model, extends beyond isolated judgments, and involves processes that enable awareness of and reflection upon experience in socially situated and intersubjective contexts6. It allows for persons to have available, in a given moment, the kind of sense of self, others, and emergent challenges necessary to adaptation and cooperation with others2. Applied to psychosis, this model has offered several significant advances. First, it has been accompanied by the development of a tool for measuring metacognitive capacity as a continuous variable: the Metacognitive Assessment Scale Abbreviated (MAS-A)4. The MAS-A differentiates metacognitive capacity according to its focus on the self, others, one's community, and the use of metacognitive knowledge. It provides subscales corresponding to these four dimensions. Higher scores on each subscale reflect a sense which involves greater levels of the integration of information, while lower scores quantify more fragmented experiences4. With adequate psychometric properties, the MAS-A has allowed for quantitative studies of subjective experience in psy­chosis internationally2, 4, 6. Relatively greater metacognitive def­icits have been detected in adults diagnosed with multiple phases of psychosis compared to healthy controls, people with non-psychiatric medical adversity, and others with less severe psychopathology. Illuminated in these studies are qualities of how individuals experience themselves as they seek to make sense of what has happened to them and what they need. Results of these studies indicate, for example, that many individuals with psychosis are able to identify discrete embodied, cognitive and emotional states, but struggle to form a coherent sense of self in which these experiences are cohesively related to one another. Thus, we are afforded a chance to dimensionally measure the experience of fragmentation which may compromise chances of the experience of oneself as an active agent in the world with coherent possibilities and purposes. The link of these alterations to disturbances in daily life are confirmed empirically by findings that graver metacognitive deficits within psychosis are linked to concurrent and prospective decrements in psychosocial functioning, including social behaviors, negative symptoms, and relatedly intrinsic motivation. Research has also found that changes in metacognition accompany changes in other aspects of function2. This work may offer an even more substantial advance as it goes beyond the recognition of a new variable affecting psychosocial functioning in psychosis. Contemporary research has affirmed that complex arrays of social and biological factors create and sustain psychosis7. Metacognition not only allows for the study of psychosis as multidetermined, but it offers a view of an underlying process that links social, biological and psychological phenomena in a fluidly interacting network which culminates in any number of possible outcomes. As supported in a recent network analysis8, metacognitive capacity may act as a central node in a complex array of heterogenous neurocognitive domains and symptoms in psychosis. In such a network, metacognitive capacity may deeply influence outcome, not only directly, but also via its influence as a node connecting and affecting the relationships among different biopsychosocial elements. Metacognition thus allows for a larger nuanced picture of the forces which shape psychosis, moving from genetics and basic brain function to socio-political issues, to phenomenology of the unique suffering, history and possibilities of a person diagnosed with psychosis. Finally, maybe most plainly, if deficits in metacognition leave persons unable to make sense of and manage experiences that accompany psychosis, then treatment which ameliorates these deficits may open unique paths to recovery. Here, there are implications for both the general principles of recovery-oriented management as well as the development of unique treatment approaches. Concerning the common elements of recovery-oriented management, metacognitive research suggests that, in order to promote a personal awareness and approach to managing psychosis, treatment has to be intersubjective in nature and emphasize joint meaning making rather than primarily offering clinician-directed approaches to symptom reduction and skill acquisition2. One intervention specifically developed on the basis of this work, metacognitive reflection and insight therapy (MERIT)9, is an integrative treatment which is responsive to patients' level of metacognitive capacity and explicitly seeks to promote the growth of this capacity over time6. With promising initial empirical support9, this operationalized treatment stands as an example of an innovation that may uniquely address the loss of persons' sense of themselves and promote self-directed recovery.