Recovery from serious mental illness has historically not been considered a likely or even possible outcome. However, a range of evidence suggests the courses of SMI are heterogeneous with recovery being the most likely outcome. One barrier to studying recovery in SMI is that recovery has been operationalized in divergent and seemingly incompatible ways: as an objective outcome versus a subjective process. Areas covered: This paper offers a review of recovery as a subjective process and recovery as an objective outcome; contrasts methodologies utilized by each approach to assess recovery; reports rates and correlates of recovery; and explores the relationship between objective and subjective forms of recovery. Expert commentary: There are two commonalities of approaching recovery as a subjective process and an objective outcome: (i) the need to make meaning out of one's experiences to engage in either type of recovery and (ii) there exist many threats to engaging in meaning making that may impact the likelihood of moving toward recovery. We offer four clinical implications that stem from these two commonalities within a divided approach to the concept of recovery from SMI.

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Metacognitive deficits are a stable feature of schizophrenia related with negative symptoms.

Research indicates that individuals with schizophrenia recover. Recovery, however means different things to different individuals and regardless of what kind of experiences define recovery, the individual diagnosed with the serious mental illness must feel ownership of their recovery. This raises the issue of how mental health services should systematically promote recovery. This paper explores the practical implications for research on metacognition in schizophrenia for this issue. First, we present the integrated model of metacognition, which defines metacognition as the spectrum of activities which allow individual to have available to themselves an integrated sense of self and others as they appraise and respond to the unique challenges they face. Second, we present research suggesting that many with schizophrenia experience deficits in metacognition and that those deficits compromise individuals’ abilities to manage their lives and mental health challenges. Third, we discuss a form of psychotherapy inspired by this research, Metacognitive Reflection and Insight Therapy which assists individuals to recapture the ability to form integrated ideas about themselves and others and so direct their own recovery. The need for recovery oriented interventions to focus on process and on patient’s purposes, assess metacognition and consider the intersubjective contexts in which this occurres is discussed.

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Research indicates that many with schizophrenia experience deficits in metacognitive capacity or the ability to form complex representations of themselves and others. Previous work has found that metacognitive capacity in schizophrenia is correlated with symptoms, insight, and neurocognitive deficits. We sought to replicate these results in a sample of Italian participants treated in a community setting. Metacognition was assessed with the abbreviated Metacognition Assessment Scale and correlated with concurrent assessment of symptoms, insight, and neurocognitive abilities, including verbal and visual memory, premorbid intelligence, processing speed, and executive function. Correlations revealed that, consistent with previous work, lesser capacity for self-reflectivity was related to greater levels of negative symptoms, poorer insight, neurocognitive impairment (particularly impairments in verbal and visual memory) premorbid intelligence, and processing speed. Other metacognitive domains were also linked to poorer neurocognition. Results support contentions that deficits in metacognition are linked with negative symptoms, insight, and neurocognitive deficits.

Recent research has suggested that recovery from psychosis is a complex process that involves recapturing a coherent sense of self and personal agency. This poses important challenges to existing treatment models. While current evidence-based practices are designed to ameliorate symptoms and skill deficits, they are less able to address issues of subjectivity and self-experience. In this paper, we present Metacognitive Insight and Reflection Therapy (MERIT), a treatment approach that is explicitly concerned with self-experience in psychosis. This approach uses the term metacognition to describe those cognitive processes that underpin self-experience and posits that addressing metacognitive deficits will aid persons diagnosed with psychosis in making sense of the challenges they face and deciding how to effectively manage them. This review will first explore the conceptualization of psychosis as the interruption of a life and how persons experience themselves, and then discuss in more depth the construct of metacognition. We will next examine the background, practices and evidence supporting MERIT. This will be followed by a discussion of how MERIT overlaps with other emerging treatments as well as how it differs. MERIT's capacity to engage patients who reject the idea that they have mental illness as well as cope with entrenched illness identities is highlighted. Finally, limitations and directions for future research are discussed.

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