embodied and narrative understandings of the self in schizophrenia: advances from the study of...

Embodied and narrative Embodied and narrative understandings of the self in understandings of the self in schizophrenia: Advances from schizophrenia: Advances from

the study of metacognition and the study of metacognition and implications for psychotherapyimplications for psychotherapy

Paul H LysakerPaul H LysakerRoudebush VA Medical CenterRoudebush VA Medical Center

And theAnd theIndiana University School of Indiana University School of

MedicineMedicine

Colleagues and collaboratorsColleagues and collaborators

Giancarlo DimaggioGiancarlo Dimaggio John LysakerJohn Lysaker Debbie WarmanDebbie Warman David RoeDavid Roe Marina KuklaMarina Kukla Kelly BuckKelly Buck Jay HammJay Hamm Benjamin BuckBenjamin Buck Susanne HarderSusanne Harder

Morris BellMorris Bell Giovanni StanghelliniGiovanni Stanghellini Phil Yanos Phil Yanos Louanne DavisLouanne Davis Giampaolo Salvatore Giampaolo Salvatore Ilanit Hasson-OhayonIlanit Hasson-Ohayon Andrew GumleyAndrew Gumley Jamie RingerJamie Ringer Jarod OutcaltJarod Outcalt

OutlineOutline A space for the intersubjective in A space for the intersubjective in biological and social models of mental biological and social models of mental illness illness Metacognition and intersubjectivityMetacognition and intersubjectivityQuantitative methods for more Quantitative methods for more assessing synthetic forms assessing synthetic forms metacognition within personal metacognition within personal narrativesnarrativesExample of empirical findings to dateExample of empirical findings to dateApplication to psychotherapyApplication to psychotherapyConclusionsConclusions

The added role of social The added role of social environmental processesenvironmental processes

NeurocognitionAnd symptoms

PsychosocialFunction

Brain Function

Genetics

Social environmental processese.g. Trauma, Stigma, Urbanicity, Lack of attachments, Poverty

A missing piece or A missing piece or neglected spaceneglected space

Neurocognitonsymptoms

Function

Brain Function

Genetics

Social environmental processes(e.g. Trauma, Stigma, Urbanicity, Lack of attachments, Poverty)

The same problem framed The same problem framed in service provisionin service provision

No home

No Self-

esteem

Provide access to work

No job

Provide access

to housing

Provide access to self

esteem

No friends

Provide access

to friends

The same problem framed The same problem framed in service provisionin service provision

access to work

No job

No friends

access

to friends

OutlineOutline A space for the intersubjective in A space for the intersubjective in biological and social models of mental biological and social models of mental illness illness Metacognition and Metacognition and intersubjectivityintersubjectivityQuantitative methods for more Quantitative methods for more assessing synthetic forms assessing synthetic forms metacognition within personal metacognition within personal narrativesnarrativesExample of empirical findings to dateExample of empirical findings to dateApplication to psychotherapyApplication to psychotherapyConclusionsConclusions

Aspects of self experience Aspects of self experience relevant to intersubjectivityrelevant to intersubjectivity

Without a valuation of life and Without a valuation of life and experience of persons with any experience of persons with any condition, we hazard undermining the condition, we hazard undermining the study of that disorder as a meaningful study of that disorder as a meaningful element of the human condition, element of the human condition, amputating the person from the disorder amputating the person from the disorder

Lysaker & Lysaker (2008). Schizophrenia and the Fate Lysaker & Lysaker (2008). Schizophrenia and the Fate of the Self. Oxford University Pressof the Self. Oxford University Press

Aspects of self experience Aspects of self experience relevant to intersubjectivityrelevant to intersubjectivity

Successful intersubjective activity Successful intersubjective activity carried out by embodied selves should carried out by embodied selves should have predictable traces, residues or have predictable traces, residues or metaphorical metabolites:metaphorical metabolites:

A complex personal narrativeA complex personal narrative

in which self and others are in which self and others are portrayed in portrayed in integrated and agentic integrated and agentic mannermanner

That is: Synthetic metacognitive activityThat is: Synthetic metacognitive activity

Related TermsRelated Terms

MetacognitionMetacognitionMentalizationMentalizationTheory of Mind (ToM)Theory of Mind (ToM)MindreadingMindreadingSocial CognitionSocial CognitionEmotional IntelligenceEmotional IntelligencePsychological MindednessPsychological MindednessMindfulnessMindfulnessObserving EgoObserving Ego

Metacognitive activitiesMetacognitive activities

Discrete activities including noticing one Discrete activities including noticing one is making an error or forming a belief is making an error or forming a belief about a specific belief – Roots in the about a specific belief – Roots in the educational literatureeducational literatureSynthetic activities including forming a Synthetic activities including forming a coherent and complex ideas about coherent and complex ideas about oneself and others and thinking about oneself and others and thinking about that – Roots in attachment and related that – Roots in attachment and related clinical literaturesclinical literatures

Level of metacognitive complexity

Metacognitive activities Core processes assessed Memory processes employed

Examples

Highly discrete processes

Noticing specific behaviors. Making accurate vs. inaccurate attributions.

Declarative and working memory

Noticing having made an error.Noticing one is performing poorly on a taskRealizing one is the source of an action or thought.

Moderately discrete processes

Thinking specific things about a relatively circumspect aspects of one’s experiences.

Endorsing vs. rejecting specific beliefs or label for a specific belief or emotion.

Declarative memory Having a specific belief about a symptom or forming a belief about something one feels.

Moderately synthetic processes

Forming coherent and integrated ideas about of oneself and others.

Representation of oneself and others which are more vs. less complex.

Autobiographical and declarative memory

Understanding how different thoughts and feelings affect each for oneself or another person.

Highly synthetic processes

Utilizing integrated ideas about oneself and others to solve psychological problems.

Utilizing more vs. less complex representations of the self and others to respond to psychological problems.

Autobiographical and declarative memory

Using an awareness of how one differs from another person in terms of thoughts and emotions to repair an interpersonal conflict.

Synthetic metacognitive Synthetic metacognitive activitiesactivities

Forming and reflecting about complex Forming and reflecting about complex representations of oneself representations of oneself Forming and reflecting about complex Forming and reflecting about complex representations of other peoplerepresentations of other peopleSituating representations of self and Situating representations of self and others in the larger world with no others in the larger world with no singular center singular center The use of complex representations of The use of complex representations of self and others to solve emergent self and others to solve emergent psychological challengespsychological challenges

NeurocognitionAnd symptoms

PsychosocialFunction

Social environmental processes

SyntheticAnd Discrete Metacognitive

Activities

Processes called for when Processes called for when assessing synthetic assessing synthetic

metacognitive activitiesmetacognitive activities

Stimuli which are Stimuli which are Affect laden Affect laden Personally relevantPersonally relevant Tied to episodic and implicit memoryTied to episodic and implicit memory Activities can occur spontaneously without Activities can occur spontaneously without

repeated cues signaling the participant to repeated cues signaling the participant to form ideas of themselves and othersform ideas of themselves and others

Assessment of metacognition Assessment of metacognition within self narratives: The within self narratives: The Indiana Psychiatric Illness Indiana Psychiatric Illness

InterviewInterview11

Interview typically lasts 30-60 minInterview typically lasts 30-60 min Interview seeks to offer an opportunity to Interview seeks to offer an opportunity to

tell about life and challengestell about life and challenges Unlike symptoms interviews specific Unlike symptoms interviews specific

aspects of illness/problems are not asked aspects of illness/problems are not asked aboutabout

Only non-directive comments are suggestedOnly non-directive comments are suggested Conversational toneConversational tone11 Lysaker PH, Clements CA, Placak Hallberg C, Knipschure SJ & Wright DE Lysaker PH, Clements CA, Placak Hallberg C, Knipschure SJ & Wright DE

(2002): Insight and personal narratives of illness in schizophrenia. (2002): Insight and personal narratives of illness in schizophrenia. Psychiatry, Psychiatry,

65, 197-206.65, 197-206.

The Indiana Psychiatric Illness The Indiana Psychiatric Illness InterviewInterview

Interview consists of 6 sets of prompts Interview consists of 6 sets of prompts which are offered as the interview which are offered as the interview progressesprogresses Tell me the story of your life.Tell me the story of your life. Do you think you have a mental illness? Do you think you have a mental illness? Because of this what has and has not changed?Because of this what has and has not changed? What do you control/what controls you?What do you control/what controls you? How does it affect others/how do others affect How does it affect others/how do others affect

it?it? What do you see in the future?What do you see in the future?

The Indiana Psychiatric Illness The Indiana Psychiatric Illness InterviewInterview

The goal is a spontaneous speech The goal is a spontaneous speech sample thatsample that Provides a glimpse about how life and the Provides a glimpse about how life and the

experience of illness are narratized.experience of illness are narratized. Provides an opportunity for synthetic Provides an opportunity for synthetic

metacognitive activity which can be rated.metacognitive activity which can be rated. Is not largely scaffolded by the interviewer.Is not largely scaffolded by the interviewer.

Assessing metacognition with Assessing metacognition with IPII narrativesIPII narratives

IPII narratives are transcribed with IPII narratives are transcribed with identifying information removedidentifying information removed

Blind raters then rate the Blind raters then rate the transcript for metacognitive transcript for metacognitive capacity using the an adapted capacity using the an adapted version of the Metacognition version of the Metacognition Assessment Scale (MAS-A)Assessment Scale (MAS-A)11

11 SEMERARI A, CARCIONE A, DIMAGGIO G, FALCONE M, NICOLO G, SEMERARI A, CARCIONE A, DIMAGGIO G, FALCONE M, NICOLO G, PROCACI M, ALLEVA G. How to evaluate metacognitive function in PROCACI M, ALLEVA G. How to evaluate metacognitive function in psychotherapy? The Metacognition assessment scale its applications. psychotherapy? The Metacognition assessment scale its applications. Clinical Psychology and Psychotherapy 2003; 10: 238-261Clinical Psychology and Psychotherapy 2003; 10: 238-261

Assessing metacognition with Assessing metacognition with IPII narrativesIPII narratives

The MAS-A consider metacognition as a The MAS-A consider metacognition as a series of semi-independent capacities.series of semi-independent capacities.

Some capacities may be more impaired Some capacities may be more impaired or more functional than othersor more functional than others

These capacities involve increasingly These capacities involve increasingly complex tasks which are largely complex tasks which are largely hierarchical in naturehierarchical in nature

The MAS-A Scales are in likert format The MAS-A Scales are in likert format and higher ratings are suggestive of and higher ratings are suggestive of greater metacognitive functiongreater metacognitive function

MAS subscalesMAS subscales Self reflectivitySelf reflectivity – – representations representations

of oneself of oneself

Understanding the mind of the Understanding the mind of the otherother – – representations of other representations of other peoplepeople

DecentrationDecentration – – situating oneself situating oneself and others in the worldand others in the world

MasteryMastery – – Using knowledge of mental Using knowledge of mental states to solve psychological problemsstates to solve psychological problems

9 Anchor points for self 9 Anchor points for self reflectivityreflectivity

1. I know there are thoughts in my head1. I know there are thoughts in my head 2. I know the thoughts are my own2. I know the thoughts are my own 3. I can distinguish different cognitive 3. I can distinguish different cognitive

operationsoperations 4. I can distinguish feelings4. I can distinguish feelings 5. My conclusions are subjective5. My conclusions are subjective 6. My wishes are not the same as reality6. My wishes are not the same as reality 7. My thoughts and feelings are connected 7. My thoughts and feelings are connected

in the momentin the moment 8. My thoughts and feelings are connected 8. My thoughts and feelings are connected

in consistent ways across many momentsin consistent ways across many moments 9. My thoughts and feelings are connected 9. My thoughts and feelings are connected

in across the larger story of my life.in across the larger story of my life.

9 Anchor points for mastery9 Anchor points for mastery 1. No plausible problems.1. No plausible problems. 2. Psychological problems but they are not plausible2. Psychological problems but they are not plausible 3. Plausible psychological problem which is responded to 3. Plausible psychological problem which is responded to

passively by altering an internal state (e.g. eating or sleeping)passively by altering an internal state (e.g. eating or sleeping) 4. Plausible psychological problem responded to by avoiding the 4. Plausible psychological problem responded to by avoiding the

issue or seeking supportissue or seeking support 5. Plausible psychological problem responded to behaviorally.5. Plausible psychological problem responded to behaviorally. 6. Plausible psychological problem responded to cognitively.6. Plausible psychological problem responded to cognitively. 7. Plausible psychological problem responded to by modifying 7. Plausible psychological problem responded to by modifying

beliefs on the basis of understanding the relationship between beliefs on the basis of understanding the relationship between cognitions, emotions, behaviors, and relationships. cognitions, emotions, behaviors, and relationships.

8. Plausible psychological problem responded to as per level 7 8. Plausible psychological problem responded to as per level 7 but also an understanding of the relationship between but also an understanding of the relationship between cognitions, emotions, and behaviors in other people. cognitions, emotions, and behaviors in other people.

9. Plausible psychological problem responded to as per above but 9. Plausible psychological problem responded to as per above but understanding that not all cannot be completely controlled.understanding that not all cannot be completely controlled.

ReliabilityReliability

Interrater reliability: significant intraclass correlations for Interrater reliability: significant intraclass correlations for all four MAS scales ranging from r = 0.61 (Decentration) all four MAS scales ranging from r = 0.61 (Decentration) to r = 0.93 (total score) - 2 raters rating 25 transcriptsto r = 0.93 (total score) - 2 raters rating 25 transcripts11. .

Internal consistency: coefficient alpha = .80, p < .05 (for Internal consistency: coefficient alpha = .80, p < .05 (for all four subscales)all four subscales)22..

Good test-retest reliability (intraclass r for 3 Good test-retest reliability (intraclass r for 3 points: .70- .84)points: .70- .84)

11Lysaker, Warman, Dimaggio, et al. (2008). Metacognition in prolonged Lysaker, Warman, Dimaggio, et al. (2008). Metacognition in prolonged schizophrenia: Associations with multiple assessments of executive function. J schizophrenia: Associations with multiple assessments of executive function. J Nerv Ment Dis Nerv Ment Dis

22Lysaker, Dimaggio, Buck et al. (2007). Lysaker, Dimaggio, Buck et al. (2007). Metacognition within narratives of Metacognition within narratives of schizophrenia: Associations with multiple domains of neurocognition. schizophrenia: Associations with multiple domains of neurocognition. Schizophr ResSchizophr Res 93: 278-287. 93: 278-287.

OutlineOutline A space for the intersubjective in A space for the intersubjective in biological and social models of mental biological and social models of mental illness illness Metacognition and intersubjectivityMetacognition and intersubjectivityQuantitative methods for more Quantitative methods for more assessing synthetic forms assessing synthetic forms metacognition within personal metacognition within personal narrativesnarrativesExample of empirical findings to Example of empirical findings to datedateApplication to psychotherapyApplication to psychotherapyConclusionsConclusions

ValidityValidity

Correlations with assessments of cognitive insight1

traditional measures of awareness of illness2

assessments of complexity of social schema using the TAT3

coping style using the Ways of Coping Questionaire4

11Lysaker, Warman, Dimaggio, et al. (2008). Metacognition in prolonged schizophrenia: Associations with multiple Lysaker, Warman, Dimaggio, et al. (2008). Metacognition in prolonged schizophrenia: Associations with multiple assessments of executive function. J Nerv Ment Dis 196: 384-389. assessments of executive function. J Nerv Ment Dis 196: 384-389.

22Lysaker, Lysaker, Carcione, Dimaggio et al (2005). Carcione, Dimaggio et al (2005). Metacognition amidst narratives of self and illness in schizophrenia: Metacognition amidst narratives of self and illness in schizophrenia: Associations with insight, neurocognition, symptom and function. Associations with insight, neurocognition, symptom and function. Acta Psychiatric ScandinavicaActa Psychiatric Scandinavica . 112, 64-71. . 112, 64-71.

33Lysaker, Dimaggio, Daroyanni et al., (2010) Assessing metacognition in schizophrenia with the Metacognition Lysaker, Dimaggio, Daroyanni et al., (2010) Assessing metacognition in schizophrenia with the Metacognition Assessment Scale: Associations with the Social Cognition and Object Relations Scale. Psychology and Assessment Scale: Associations with the Social Cognition and Object Relations Scale. Psychology and PsychotherapyPsychotherapy

44Lysaker PH, Erickson MA, Ringer J, et alLysaker PH, Erickson MA, Ringer J, et al. (In press). . (In press). Metacognition in schizophrenia: the relationship of mastery to Metacognition in schizophrenia: the relationship of mastery to coping, insight, self-esteem, social anxiety and various facets of neurocognition. coping, insight, self-esteem, social anxiety and various facets of neurocognition. British Journal of Clinical British Journal of Clinical Psychology.Psychology.

A missing piece or A missing piece or neglected spaceneglected space

Neurocognitonsymptoms Function

Brain Function

Genetics

Social environmental processese.g. Trauma, Stigma, Urbanicity, Lack of attachments, Poverty

Self reflectivity predicting work Self reflectivity predicting work function over the next 6 monthsfunction over the next 6 months

56 males with schizophrenia or schizoaffective 56 males with schizophrenia or schizoaffective disorderdisorder Modal age: Late 40s; Modal education: 12 yearsModal age: Late 40s; Modal education: 12 years In outpatient treatment at a VA Medical Center or In outpatient treatment at a VA Medical Center or community mental health centercommunity mental health center Often with a history of multiple hospitalizations Often with a history of multiple hospitalizations Prescribed anti-psychotic medicationPrescribed anti-psychotic medication Completed 4 of a 6 month vocational Completed 4 of a 6 month vocational placementsplacements

Lysaker PH, Dimaggio G, Carcione A, et al., (2010). Lysaker PH, Dimaggio G, Carcione A, et al., (2010). Metacognition and Schizophrenia: The capacity for self- Metacognition and Schizophrenia: The capacity for self- reflectivity as a predictor for prospective assessments of reflectivity as a predictor for prospective assessments of work performance over six months. work performance over six months. Schizophrenia ResearchSchizophrenia Research. . 122(1-3), 124-130122(1-3), 124-130

(n = 21, 22, 13)(n = 21, 22, 13)

Effects of neurocognition upon Effects of neurocognition upon social function are mediated by social function are mediated by

metacognition: Path analysismetacognition: Path analysis N = 102 with schizophrenia or schizoaffective N = 102 with schizophrenia or schizoaffective disorderdisorder Male and female; Age: Late 40s ; Modal education: Male and female; Age: Late 40s ; Modal education: 12 yrs12 yrs In outpatient treatment at a VA Medical Center or In outpatient treatment at a VA Medical Center or community mental health centercommunity mental health center Often with a history of multiple hospitalizations Often with a history of multiple hospitalizations Prescribed anti-psychotic medicationPrescribed anti-psychotic medication No hospitalizations within the last monthNo hospitalizations within the last month

Lysaker PHLysaker PH,, Shea AM, Buck KD, et al., (2010) Shea AM, Buck KD, et al., (2010) Metacognition as a Metacognition as a mediator of the effects of impairments in neurocognition on social mediator of the effects of impairments in neurocognition on social function in schizophrenia spectrum disorders. function in schizophrenia spectrum disorders. Acta Psychiatrica Acta Psychiatrica ScandinavicaScandinavica 122(5), 405-413. 122(5), 405-413.

MethodsMethods

Neurocognitive assessments:Neurocognitive assessments: Wisconsin Card sorting testWisconsin Card sorting test Hopkins Verbal Learning TestHopkins Verbal Learning Test WAIS III VocabularyWAIS III Vocabulary WAIS III Digit SymbolWAIS III Digit Symbol WMS III Visual ReproductionWMS III Visual Reproduction

Metacognition rated from typed Metacognition rated from typed transcribed narratives by a blind rater using transcribed narratives by a blind rater using the MASthe MAS Assessment of social connections and Assessment of social connections and capacity for relatedness obtained using the capacity for relatedness obtained using the Heinrichs Quality of Life scale (QOLS) Heinrichs Quality of Life scale (QOLS) interview interview Symptoms assessed using the PANSSSymptoms assessed using the PANSS

ProcedudresProcedudres

Neurocognitive assessments reduced to a Neurocognitive assessments reduced to a factor using a principal components factor using a principal components analysis:one (Eigenvalue = 2.40) which analysis:one (Eigenvalue = 2.40) which accounted for 48% of the variance.accounted for 48% of the variance.

Path Analysis using LISREL 8.8Path Analysis using LISREL 8.8

Model fit evaluated with chi-square Model fit evaluated with chi-square statistic (χ2), root mean square error of statistic (χ2), root mean square error of approximation (RMSEA), Comparative Fit approximation (RMSEA), Comparative Fit Index (CFI), Goodness of Fit Index (GFI), and Index (CFI), Goodness of Fit Index (GFI), and the standardized root mean square the standardized root mean square residuals (SRMR).residuals (SRMR).

NeurocognitionFactor score

for 5 variables

QOLS IntrapsychicFoundations

MetacognitionMAS

MasteryScore

QOLSInterpersonal

relations

NeurocognitionFactor score

for 5 variables

QOLS IntrapsychicFoundations

MetacognitionMAS

MasteryScore

QOLSInterpersonal

relations

r =. 23r =.37

r =.27

r =.30

r =.16

Path Model of Mastery as a mediator of the impact of neurocognition on social function controlling fornegative and cognitive symptoms

Path analysis Mastery and social function with assessments 5 months apart

Lysaker PH, Erickson MA, Buck KD, et al. (2011). Metacognition and social function in schizophrenia: Associations over a period of five months. Cognitive Neuropsychiatry 16(3), 241-55

Davis LW, Eicher AC, & Lysaker PH. (2011). Metacognition as a Davis LW, Eicher AC, & Lysaker PH. (2011). Metacognition as a predictor of therapeutic alliance over 26 weeks of psychotherapy predictor of therapeutic alliance over 26 weeks of psychotherapy

in schizophrenia. in schizophrenia. Schizophrenia Research, Schizophrenia Research, 129(1): 85-90.129(1): 85-90.

Mastery and working alliance in Mastery and working alliance in cognitive therapycognitive therapy

Persons with HIV+ exhibit greater metacognitive capacity when engaging in our narrative task compared with patients with schizophrenia

_____________________________________________________________Schizophrenia HIV+ F P <(n= 45) (n=25)

______________________________________________________________ MAS Self reflectivity 4.16 (1.57) 6.22 (1.77) 12.620.001MAS Mind of the Other 2.85 (1.07) 4.60 (1.32) 20.420.001MAS Decentration 0.89 (0.95) 1.86 (0.82) 8.19

0.006MAS Mastery 3.35 (1.49) 5.64 (1.87) 16.540.001______________________________________________________________

Lysaker PH, Ringer JM, Buck KD, Grant MLA, Olesek K, Leudtke B & Dimaggio D. (In press) Metacognitive and social cognition deficits in patients with significant psychiatric and medical adversity: a comparison of participants with schizophrenia and a sample of participants who are HIV+. Journal of Nervous and Mental Disease

Other FindingsOther FindingsAfter controlling for neurocognition and After controlling for neurocognition and symptoms Mastery is linked tosymptoms Mastery is linked to

A biases to jump to conclusions in probabilistic A biases to jump to conclusions in probabilistic reasoning task reasoning task Performance on the planning comprehension Performance on the planning comprehension subscale of the UPSAsubscale of the UPSA

Buck KD, Warman DM, Huddy V & Lysaker PH (In press). The Buck KD, Warman DM, Huddy V & Lysaker PH (In press). The relationship of metacognition with jumping to conclusions among relationship of metacognition with jumping to conclusions among persons with schizophrenia spectrum disorders. persons with schizophrenia spectrum disorders. PsychopathologyPsychopathology

Lysaker PHLysaker PH, , McCormick BP, Snethen G, Buck KD, Hamm JA, Grant McCormick BP, Snethen G, Buck KD, Hamm JA, Grant MLA, Nicolò G & Dimaggio G. (In press). Metacognition and social MLA, Nicolò G & Dimaggio G. (In press). Metacognition and social function in schizophrenia: Associations of mastery with functional function in schizophrenia: Associations of mastery with functional skills competence. skills competence. Schizophr ResSchizophr Res

Other FindingsOther Findings MAS-A and ToM capacities have a unique MAS-A and ToM capacities have a unique links with different domains of insightlinks with different domains of insight

Self-reflectivity is most closely linked to Self-reflectivity is most closely linked to awareness of symptomsawareness of symptomsAwareness of the other was correlated to Awareness of the other was correlated to awareness of treatment needsawareness of treatment needsMastery and the Hinting Test were correlated to Mastery and the Hinting Test were correlated to awareness of consequence of illnessawareness of consequence of illness

Lysaker PH, Dimaggio G, Buck KD, Callaway SS, Salvatore G, Lysaker PH, Dimaggio G, Buck KD, Callaway SS, Salvatore G, Carcione A, Nicolò G & Stanghellini G. (2011). Poor insight in Carcione A, Nicolò G & Stanghellini G. (2011). Poor insight in schizophrenia. schizophrenia. Comprehensive Psychiatry.52(3)Comprehensive Psychiatry.52(3) 253-260. 253-260.

Ongoing studiesOngoing studies

MAS-A predicts function in a Turkish sample with MAS-A predicts function in a Turkish sample with symptoms remission (poster presented) symptoms remission (poster presented) MAS-A and PANSS ratings in an Italian schizophrenia MAS-A and PANSS ratings in an Italian schizophrenia sample (submitted)sample (submitted)MAS-A and attachment in a Scottish first episode MAS-A and attachment in a Scottish first episode sample (data collected)sample (data collected)MAS-A and depression in a Danish sample (data MAS-A and depression in a Danish sample (data collected)collected)MAS-A and first episode psychosis sample in a MAS-A and first episode psychosis sample in a French Canadian sample (data collected) French Canadian sample (data collected) MAS-A and first episode psychosis sample in an MAS-A and first episode psychosis sample in an Israeli sample (data collected) Israeli sample (data collected) MAS-A in combat PTSD and their partners (data MAS-A in combat PTSD and their partners (data collection)collection)MAS-A in homeless sample (data collection)MAS-A in homeless sample (data collection)

Psychotherapy could be a place to Psychotherapy could be a place to develop various capacities for develop various capacities for metacognition:metacognition:

*Self reflectivity*Self reflectivity*Mastery*Mastery*Decentration*Decentration

Interventions could be keyed to Interventions could be keyed to help persons to practice help persons to practice metacognitive acts consonant with metacognitive acts consonant with their current abilitiestheir current abilities

MAS could assess change over timeMAS could assess change over time

Targeting a capacity – not content Targeting a capacity – not content or solving an issue or problemor solving an issue or problem

Helping people practice and learn Helping people practice and learn to perform a particular cognitive to perform a particular cognitive act act

Seeing improvements as occurring Seeing improvements as occurring along on a continuum – not as along on a continuum – not as categoricalcategorical

Two casesTwo cases

Lysaker PH, Davis LD, Eckert GJ, Strasburger A, Hunter Lysaker PH, Davis LD, Eckert GJ, Strasburger A, Hunter N & Buck, KD (2005). Changes in narrative structure N & Buck, KD (2005). Changes in narrative structure and content in schizophrenia in long term individual and content in schizophrenia in long term individual psychotherapy: A single case study. psychotherapy: A single case study. Clinical Psychology Clinical Psychology and Psychotherapyand Psychotherapy. 12, 406-416.. 12, 406-416.

Lysaker PH & Hermans HJM. (2007). The dialogical self Lysaker PH & Hermans HJM. (2007). The dialogical self in psychotherapy for persons with schizophrenia: A case in psychotherapy for persons with schizophrenia: A case study. study. Journal of Clinical PsychologyJournal of Clinical Psychology, 63, 129-139, 63, 129-139

Lysaker PH, Buck KD & Ringer J (2007). The recovery of Lysaker PH, Buck KD & Ringer J (2007). The recovery of metacognitive capacity in schizophrenia across thirty metacognitive capacity in schizophrenia across thirty two months of individual psychotherapy: A case study. two months of individual psychotherapy: A case study. Psychotherapy Research. 17, Psychotherapy Research. 17, 713 - 720 713 - 720

Case 1: Greig Case 1: Greig 11 Divorced man in his 50s Divorced man in his 50s High school education High school education Lived in his communityLived in his community Outpatient psychiatric care for undifferentiated Outpatient psychiatric care for undifferentiated

schizophrenia. schizophrenia. Hallucinations, delusions thought disorder since his early Hallucinations, delusions thought disorder since his early

20s 20s No periods of symptom remission.No periods of symptom remission. Blunted affect and lack of volition Blunted affect and lack of volition Disorganized speech and significant levels of anxiety. Disorganized speech and significant levels of anxiety. Multiple hospitalizations, lost jobs, social alienation, Multiple hospitalizations, lost jobs, social alienation, No substance abuse or legal problems. No substance abuse or legal problems. Grave impairments in memory and executive functionGrave impairments in memory and executive function

11All identifying information in this report has been All identifying information in this report has been systematically disguisedsystematically disguised

Sketch of Greig’s progress over Sketch of Greig’s progress over 2.5 years2.5 years

Exploration/confrontation of delusions Exploration/confrontation of delusions Discussion of conflicting feelings about Discussion of conflicting feelings about

adult children adult children Processing losses inherent in divorcesProcessing losses inherent in divorces Focus on inability to loveFocus on inability to love Discussion of sense of “self-as-loser”Discussion of sense of “self-as-loser” Detailing his symptoms of mental Detailing his symptoms of mental

illnessillness

Case 1: GreigCase 1: Greig Two transcripts per month selected Two transcripts per month selected MAS blindly rated for MAS for the MAS blindly rated for MAS for the

first 32 weeksfirst 32 weeks MAS rated for exploratory MAS rated for exploratory

purposes for the following 2 yearspurposes for the following 2 years Correlation of MAS with time is Correlation of MAS with time is

0.70; p < .00010.70; p < .0001

0 6 12 18 24 30

Months

05

1015

2025

30

MA

S T

otal

Sco

re

Case 2: ScarlattiCase 2: Scarlatti11 Divorced man in his 40s Divorced man in his 40s College education College education Lived in his communityLived in his community Received outpatient psychiatric care for paranoid Received outpatient psychiatric care for paranoid

schizophrenia. schizophrenia. Hallucinations and delusions since his early 20s Hallucinations and delusions since his early 20s No periods of symptom remission.No periods of symptom remission. Denial of illness Denial of illness Pressured speech and significant levels of anxiety. Pressured speech and significant levels of anxiety. Multiple hospitalizations, lost jobs, social alienation, Multiple hospitalizations, lost jobs, social alienation,

substance abuse and legal problems. substance abuse and legal problems. Grave impairments in memory Grave impairments in memory

11All identifying information is systematically disguisedAll identifying information is systematically disguised

Case 2: Scarlatti Case 2: Scarlatti

De-idenitifed psychotherapy De-idenitifed psychotherapy transcript selected one per month for transcript selected one per month for 32 months32 months

MAS and Delusions from the Positive MAS and Delusions from the Positive and Negative Syndrome Scale rated and Negative Syndrome Scale rated by 2 raters by 2 raters

Raters blindRaters blind

Metacognition and Metacognition and Delusions Delusions

32

31

30

29

28

27

26

25

24

23

22

21

20

19

18

17

16

15

14

13

12

11

10

987654321

observation number

0.80

0.70

0.60

0.50

0.40

0.30

0.20

0.10

Me

an

metacognition

delusions

Metacognition by Metacognition by domaindomain

3231302928272625242322212019181716151413121110987654321

observation number

8.00

7.00

6.00

5.00

4.00

3.00

2.00

1.00

Mastery

Awareness of other

Self reflectivity

OutlineOutline

A space for the person in biological A space for the person in biological and social models of mental illness and social models of mental illness Metacognition and its relevancy for Metacognition and its relevancy for recoveryrecoveryQuantitative methods for Quantitative methods for metacognition within personal metacognition within personal narrativesnarrativesExample of empirical findings to dateExample of empirical findings to dateApplication to psychotherapyApplication to psychotherapyConclusionsConclusions

ConclusionsConclusions

The study of schizophrenia is not The study of schizophrenia is not complete without the consideration of complete without the consideration of the personthe person

How persons thinking about their How persons thinking about their thinking mediates the impact of thinking mediates the impact of schizophrenia. schizophrenia.

Synthetic metacognitive activities may Synthetic metacognitive activities may be assessed quantitatively.be assessed quantitatively.

Metacognition may be a foci of Metacognition may be a foci of psychotherapy.psychotherapy.

LimitationsLimitations

One form of assessment of One form of assessment of metacognitionmetacognition

Studies were conducted in one labStudies were conducted in one lab Participants were generally in their Participants were generally in their

40s in a later stage of illness40s in a later stage of illness Replication is needed with more Replication is needed with more

diverse samplesdiverse samples Longitudinal studies are warrantedLongitudinal studies are warranted

embodied and narrative understandings of the self in schizophrenia: advances from the study of...

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