Poor insight or unawareness of illness has been commonly observed in schizophrenia and has been long recognized as a potent barrier to treatment adherence and a risk factor for a range of poorer outcomes. Paradoxically, the achievement of insight often poses a different set of problems including depression and low self-esteem. One barrier to the treatment of poor insight has been a lack of understanding of the phenomenon, which causes poor insight to develop and persist over time. Without knowing what promotes poor insight, treatment to date has had little to offer beyond the supportive provision of information. To explore these issues, this article reviews emerging literature on the correlates of poor insight in schizophrenia, and newly developing ways of conceptualizing insight. It then details a number of innovative integrative group and individual treatment approaches in the early stages of development, which take into account some of the potential causal forces behind poor insight, including deficits in neurocognition, social cognition, metacognition and heightened self-stigma. A plan for further research is presented to develop a model of the factors whose interaction influences insight, and to refine and test integrative treatments.
Schizophrenia often involves a loss of metacognitive capacity, the ability to form complex and integrated representations of self and others. Independent of symptoms and neurocognition, deficits in synthetic metacognition are related to difficulties of engaging in goal-directed activities in social and vocational settings. Within this backdrop, we provide a case report of the effects of Metacognitive Reflective Insight Therapy (MERIT) that assisted a patient suffering from first episode schizophrenia during 2 years of individual psychotherapy. A total of 8 elements of MERIT that stimulate and promote metacognitive capacity are presented. As illustrated in this report, these procedures helped the patient move from a state in which he had virtually no complex ideas about himself or others to one in which he had developed integrated and realistic ideas about his own identity and the identity of others. He then could use these representations to understand and effectively respond to life challenges.
Historical and contemporary perspectives have argued that alterations in self-experience in psychosis can be reversed with the help of psychotherapy. Less is known about the particular forces that spur such change, though it has been argued that intersubjectivity in the therapy dyad contributes to shared meaning making that enables movement toward recapturing a sense of self. To date, it is unclear how exactly the therapist establishes and then maintains an intersubjective connection in psychotherapy with persons with psychosis.In this article, we offer a three-step hierarchical model that describes observable therapist activities that promote intersubjectivity and facilitate the recovery process for individuals experiencing psychosis. We suggest the therapist activities needed to build mutual sense making include a foundational therapist openness to experience, which leads to the development of a dialectic of acceptance-challenge to fragmentation, and ultimately joint reflection that contributes to recovery of sense of self. The clinical implications and challenges of incorporating these types of interventions into clinical practice are discussed.
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