Capacidad Reflexiva en Esquizofrenia

8/18/2019 Capacidad Reflexiva en Esquizofrenia

1/11

Reawakening Reective Capacity in the Psychotherapyof Schizophrenia: A Case Study

Rebecca Bargenquast, Robert D. Schweitzer, and Suzanne Drake

Queensland University of Technology

Disturbed sense of self has long been identied as a common experience among people suffering withschizophrenia. More recently, metacognitive decits have been found to be a stable and independentfeature of schizophrenia that contributes to disturbed self-experience and impedes recovery. Individualpsychotherapy designed to target poor metacognition has been shown to promote a more coherentsense of self and enhanced recovery in people with schizophrenia. We provide a report of a 2-yearindividual psychotherapy with a patient suffering with chronic schizophrenia. Progress was assessedover the course of treatment using the Metacognition Assessment Scale and the Brief Psychiatric RatingScale. The patient experienced improved metacognitive capacity and reduced symptom severity overthe course of therapy. Implications for clinical practice are discussed. C 2015 Wiley Periodicals, Inc. J.

Clin. Psychol.: In Session 71:136–145, 2015.

Keywords: schizophrenia; psychotherapy; metacognition; narrative; recovery

Loss of self is, arguably, at the core of the psychopathology in people suffering from psychosis.People diagnosed with schizophrenia are observed as suffering from a profound sense of beingcutoff from themselves and the outside world, with the disorder having been dened as an“I am illness–one that may overtake andredene the identity of theperson” (Estroff,1989,p. 189).Although the symptoms of schizophrenia are heterogeneous, disturbed sense of self has longbeen identied as a common experience among sufferers, with some arguing that schizophreniais fundamentally a self disorder (Davidson, 2003; Jacobson, 2002; Lysaker & Lysaker, 2008;Roe & Ben-Yishai, 1999; Sass & Parnas, 2003; Stanghellini, 2004). Recent advances in the eldhave linked disturbed self-experience in people diagnosed with schizophrenia with impairedmetacognitive capacity, that is, the ability to think meaningfully about one’s own thoughts andfeelings and the thoughts and feelings of others (Lysaker, Buck, Taylor, & Roe, 2008).

Metacognition is a multifaceted construct that comprises a range of functions, from discreteacts of reection to more complex acts involving the integration of multiple perceptions (Lysakeret al., 2011). Metacognition involves operations such as recognizing and differentiating ouremotions, making links between our mental states and our behavior, recognizing that our beliefsabout ourselves and others are subjective and others may see things differently, identifying thereasons behind others mental states and behavior, and using our understanding of our mentalstates to implement strategies to manage distress. Metacognition is related to concepts such astheory of mind, reective functioning, mind-mindedness, empathy, and mentalization. Decitsin metacognitive functions are a stable feature of schizophrenia and contribute to sufferers’difculties with drawing plausibleconclusions about the origins of internal states and the motivesof others (Frith, 1992; Lysaker, Dimaggio, Buck, Carcione, & Nicolo, 2007).

Metacognitive decits have also been linked to difculties in developing meaning from ex-periences, severity of delusions, poor insight, trouble constructing coherent and meaningfulnarratives, and diminished sense of self, all of which are barriers to recovery (Harrington,Langdon, Siegert, & McClure, 2005; Lysaker, Carcione, et al., 2005).

Recent research has suggested that we may conceive of metacognitive capacity in terms of the following abilities: (a) understanding one’s own mind, which is the capacity to recognize,

Please address correspondence to: Robert Schweitzer, School of Psychology and Counselling, QueenslandUniversity of Technology, Kelvin Grove QLD, Australia. E-mail: [email protected]

JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION , Vol. 71(2), 136–145 (2015) C 2015 Wiley Periodicals, Inc.Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.22149


2/11

Reawakening Reective Capacity 137

Table 1Levels of Metacognitive Capacity Using the Metacognition Assessment Scale

Understanding one’s own mind (nine levels)

1. Acknowledges having mental functions.2. Represents self as a person with autonomous thoughts and feelings.3. Denes and distinguishes own cognitive operations.4. Denes and distinguishes own emotional states.5. Recognizes the subjectivity and fallibility of representations of self and the world6. Recognizes the limited impact thoughts and wishes have on reality.7. Recognizes that their behavior may be determined by their thoughts and feelings.8. Constructs complete description of their mental state differentiating between thoughts

and feelings.9. Integrates different modes of cognitive and emotional functioning into a coherent and

complex narrative.

Understanding others’ minds (seven levels)

1. Acknowledges others have mental functions.2. Represents others as persons with autonomous thoughts and feelings.3. Denes and distinguishes others’ cognitive operations.4. Denes and distinguishes others’ emotional states.5. Makes plausible inferences about others’ mental states.6. Constructs a complete description of others’ mental states differentiating between

cognitive and emotional factors.7. Integrates others’ different modes of cognitive, emotional, and relational functioning

into a coherent narrative.

distinguish, and integrate one’s own mental states; (b) understanding others’ minds, which isthe capacity to understand others’ mental states and form integrated representations of otherpeople; (c) decentration, which is the capacity to recognize that one is not at the center of others’ lives; and (d) mastery, which is the capacity to use metacognitive knowledge to cope withpsychological problems (Semerari et al., 2003).

Based on these constructs, the Metacognitive Assessment Scale (MAS) was developed, andlater adapted in an abbreviated form (MAS-A), to measure metacognitive capacity in peoplediagnosed with schizophrenia spectrum disorders (Lysaker, Carcione, et al., 2005; Semerari,

et al., 2003). The MAS-A measures metacognitive capacity along a continuum from less tomore complex acts (see Table 1). These constructs both inform and increase our insight andunderstanding of the primary decits in schizophrenia and have, in part, guided the developmentof Metacognitive Narrative Psychotherapy.

Metacognitive Narrative Psychotherapy

Drawing upon the conception of schizophrenia outlined above, the proposed treatment model,Metacognitive Narrative Psychotherapy, involves patients “developing a renewed sense of theirillness, identity, agency, and worth within their life stories” (Lysaker & Buck, 2006, p. 233). Theapproach, developed by Lysaker and colleagues (Lysaker et al., 2011), draws upon a psychother-

apeutic approach developed for the treatment of personality disorders (Dimaggio, Semerari,Carcione, Nicol ¯ o, & Procacci, 2007). Metacognitive Narrative Psychotherapy aims to addressthe subjective aspects of the recovery process by offering a therapeutic framework that helpspeople with schizophrenia recover richer experiences of themselves by improving capacities formetacognition and facilitating the development of more coherent, richer narratives within aninterpersonal context.


3/11

138 Journal of Clinical Psychology: In Session, February 2015

Metacognitive Narrative Psychotherapy has been described as an approach that prioritizescollaboration, enables reection, encourages the exploration of strengths and difculties, andassists in the making of connections between the past, present, and future. The approach offerspatients opportunities to practice acts of metacognition (e.g., think about their own thinkingand feelings, and the thinking and feelings of others) and, as such, strengthen their ability to

perform more complex metacognitive functions within therapy sessions and in their life outsideof treatment (Lysaker et al., 2011; Lysaker, Glynn, Wilkniss, & Silverstein, 2010). Interventionsmay involve reecting upon the metacognitive function patients are engaging in, “You areremembering playing with your sister as a child,” which targets level 3 of understanding one’sown mind (see Table 1), or gently challenging them to engage in more complex metacognitiveacts, “How does it feel to talk to me about this?” which targets level 4 of understanding one’sown mind (see Table 1).

The approach takes into account that capacities for metacognition vary between people, withsome able to perform only very basic acts and others able to perform more complex acts. Forexample, a person may be able to dene and distinguish his or her own cognitive operations,recognizing the difference between thinking, remembering, and planning, but struggle to dene

and distinguish his or her own emotional states in a nuanced way. To ensure appropriate inter-ventions, the therapist is required to actively assess the patient’s metacognitive capacities withineach session to ensure interventions are in line with the patient’s abilities in the moment. Thiscan be done with reference to the MAS-A.

Metacognitive Narrative Psychotherapy also targets narrative coherence and richness in peo-ple with schizophrenia, recognizing the interdependent relationship between metacognitive ca-pacityandabilityfor coherent storytelling. “Withoutmetacognitive capacity it shouldbe difcultto evolve a complex storied understanding of one’s life, and without a sense that one’s life is worthtelling a story about, there should be little need for complex acts of metacognition” (Lysakeret al., 2010, p. 82). Storytelling, and, in turn, capacity to reect upon mental states, is furtherfacilitated by emphasizing the rst-person experience of the patient, recognizing the patient as a

protagonist in the stories told, reecting on the therapist as audience to the stories told, assistingthe patient to remember, link and lter information, and identifying stories that remain untold(Lysaker, Buck, & Hammoud, 2007; Lysaker, Buck, & Roe, 2007; Lysaker & Lysaker, 2011).

A principle-based manual for the approach was developed by Bargenquast and Schweitzer(2013b). The manual outlines ve phases of treatment: (a) developing a therapeutic relation-ship, (b) eliciting narratives, (c) enhancing metacognitive capacity, (d) enriching narratives, and(e) living enriched narratives. Progression through the phases of Metacognitive Narrative Psy-chotherapy is related to patients’ developing richer life stories, more fullling connections withothers, an enhanced sense of coherence, improved volition and agency, a belief that they arevalued by others, and a more complex, coherent sense of self.

Evidence Base

A series of case studies of peoplewith schizophrenia spectrum disordershasshown that Metacog-nitive Narrative Psychotherapy is connected to improvements over time in metacognitive capac-ity, narrative richness and coherence, and ability to portray oneself as an active agent with socialconnections and value (Buck & Lysaker, 2009; Lysaker, Buck, & Ringer, 2007; Lysaker, Davis,et al., 2005; Lysaker, Davis, Jones, Strasburger, & Beattie, 2007; Lysaker & Gumley, 2010). Inconjunction with metacognitive and narrative improvements, case studies have also revealedimprovements in social and emotional functioning, including increased independence, improvedrelationships with family and friends, increased insight, and a reduction in positive and negativesymptoms (Lysaker, Buck, & Hammoud, 2007; Lysaker, Davis, et al., 2007; Salvatore et al.,

2009).More recently, a pilot study of 11 people diagnosed with schizophrenia investigated theeffectiveness of the manualized version of Metacognitive Narrative Psychotherapy over thecourse of 11 to 26 months (Bargenquast & Schweitzer, 2013a). Results showed that patientsdemonstrated signicant improvement in subjective recovery and self-reectivity over the courseof treatment. The ndings highlighted the potentially important role of psychological treatment


4/11


in the recovery process for people diagnosed with psychotic spectrum disorders. Althoughevidence supporting the approach developed and described by Lysaker and colleagues is growingand a multisite randomized controlled trial is underway (Van Donkersgoed et al., 2014), thegeneralizability of the model across settings continues to be unknown. An in-depth case studyapproach is often the rst priority in developing a novel intervention, with a view to gaining

a better understanding of the mechanisms of change involved in the implementation of theapproach.

Case Illustration

Presenting Problem and Client Description

Clancy was an unemployed male in his 60s. He had never been married and was living aloneon a disability pension. He had a 40-year history of psychosis, experiencing his rst psychoticepisode and psychiatric hospitalization in mid-adolescence. His mental health difculties wereassociated with at least 10 inpatient admissions, poor vocational functioning, and profound

social disconnection. At the beginning of psychotherapy, he had not had a psychiatric hospital-ization for about 20 years, although he regularly presented to emergency services with akathisiaand apparent anxiety.

He initially presented with negative symptoms and an array of unusual persecutory andgrandiose ideas including extreme suspiciousness regarding the motives of others, concernsregarding the Catholic Church, and a belief he was being scouted for the Olympic runningteam. Beliefs were not tenaciously held but represented attempts to make sense of seeminglyconfusing and conicting internal and external experiences. During the rst session, Clancyexpressed signicant feelings of anxiety and fear and evidenced a marked lack of personalagency. He reported a vast array of somatic complaints that seemed to have little physiologicalbasis. The stories he told lacked major details and a sense of being placed in time, making

them difcult to follow. Clancy had limited awareness of his own mental states, especially hisemotional experiences, and he struggled to understand others’ behavior. His pretreatment ratingon the Brief Psychiatric Rating Scale (BPRS; Lukoff, Liberman, & Nuechterlein, 1986) placedhim in the “markedly ill” range (Leucht et al., 2005).

Clancy was born into an Irish Catholic family and was one of ve children. He was unsure of any family history of mental illness. However, he alluded to his mother experiencing emotionaldifculties during his childhood. His parents remained married throughout their lives and hadpassed away 15 years prior to Clancy commencing treatment. He continued to have intermittentcontact with three of his sisters, who provided some nancial and social support. He frequentedan art group for people with mental illness. Clancy often experienced social interaction asconfusing and threatening, and he reported a long history of never tting in. He had never been

married, had no children, and denied any history of romantic relationships. In his youth, heachieved well academically until he became unwell and had to drop out of high school. In lateadolescence Clancy completed his Year 12 equivalency and worked intermittently throughouthis 20s. At the beginning of therapy Clancy had not worked for over 20 years.

Case Formulation

Clancy met diagnostic criteria for chronic schizophrenia, characterized by negative symptomsand nonbizarre delusions. There was no evidence of personality disorder. He suffered fromakathisia due to long-term antipsychotic medication use. He was deaf in one ear due to a geneticcondition for which he wore a hearing aid.

Initially, Clancy presented with little to say about his history and the people in his life at thattime. He would merely repeat sparse details of his daily activities with little expression of histhoughts and feelings. It was near impossible to gain a sense of who he was as a person. Hisstories were barren, representing an inner world characterized by a sense of emptiness and, attimes, nonexistence (Lysaker & Lysaker, 2002). We understood that the development of a morestable sense of self was interrupted by the onset of psychosis during his adolescence, in which


5/11


Clancy’s awareness of his and others’ mental states appeared to be greatly effected. Decades of social isolation, difculties understanding his internal experiences, and an ever present sense of threat had left Clancy with little sense of who he was apart from being “schizophrenic.” Formany years the only story he had been hearing was “You have schizophrenia and you need totake medication,” leaving his inner world depleted.

Early assessments suggested Clancy experienced poor metacognitive capacity, which meantthat he struggled to make sense of his internal experiences and the motives of others leading toa chronic sense of fear and persecution. Internal stimuli such as a painful memory or a feelingof loneliness triggered immense confusion and subsequent poor attempts to make sense of hisexperiences. In the absence of meaningful self-reection, Clancy used somatic complaints ordelusional beliefs to understand affective experiences. In this sense, we believed Clancy’s psy-chiatric symptoms, such as somatizing and delusional ideation, served an important functionalpurpose by providing him with a meaningful sense of who he was and warding off an otherwiseoverwhelming sense of confusion and nothingness. We conceived of his psychotic experiences asboth compensating for and maintaining his impaired metacognitive capacity.

Course of Treatment

Clancy’s treatment was part of a larger pilot study of the effectiveness of Metacognitive NarrativePsychotherapy. The outcomes of this trial are published elsewhere (Bargenquast & Schweitzer,2013a). His psychiatrist referred him to the research project. During the duration of his psy-chotherapy, Clancy was prescribed an antipsychotic medication and benzodiazepine to use asneeded for sleep and anxiety. This was the rst time Clancy was given the opportunity to engagein individual psychotherapy, having been managed primarily on medication.

Psychotherapy sessions were weekly and lasted 45 minutes for the course of 26 months. Clancyattended 97% of his scheduled sessions, totaling 88 sessions. The end of treatment coincided withthe end of the larger research project and, as such, was a forced termination. The psychotherapist

(RB) was a novice psychologistcompleting her research dissertationon psychotherapy for peoplediagnosed with schizophrenia. Treatment was supervised by an experienced clinical psychologistand psychotherapist (RS).

Clancy’s treatment was guided by the treatment manual Metacognitive Narrative Psychother-apy: Guiding Principles and Practice (Bargenquast & Schweitzer, 2013b). The manual providedthe therapist with a set of general principles to guide the psychotherapy sessions. While a manualwas used to guide practice, sessions were not conducted prescriptively. Instead, the process of change was considered unpredictable and unique to the patient. Psychotherapy rarely followed alinear path. Improvements were often followed by setbacks, which were then followed by furtherprogress.

Early phase of treatment: Developing a therapeutic relationship and eliciting narra-tives. The early sessions, drawing upon phases 1 and 2 of the manual, focused on the develop-ment of a shared partnership between Clancy and his therapist. The therapist worked hard topromote a sense of safety, with Clancy initially presenting to sessions as confused and suspicious.Clancy had always found social interaction perplexing, which meant his therapist needed to bevery specic about the aims of the sessions, her role in relation to Clancy’s treatment, and themotives that informed her interventions during sessions. Questions would often include caveatssuch as, “I’m asking about your experience of our session today because it can be helpful for meto have feedback from you to make sure we are working well together.”

The therapeutic process was made as explicit as possible. External boundaries such as the timeand place of sessions were made clear and remained consistent as much as possible throughout

the treatment. Clancy often expressed his surprise and appreciation of sessions starting andending on time. It seemed that attention to boundaries offered a sense of predictability that wasvery comforting and potentially therapeutic.

The therapist adopted a reective, not-knowing stance. Space was created, within the contextof the therapeutic relationship, to think about Clancy’s internal experiences. For instance, “Let ustake some time to think about what was going on for you when you felt like everyone was talking


6/11


about you.” Interventions largely involved reecting upon small, concrete fragments of Clancy’sself-experience. He often spoke about his daily activities to which the therapist responded withstatements emphasizing his rst person experience, “ You went grocery shopping today,”

Although Clancy showed some awareness of his cognitive operations during this early phaseof treatment, his reections were sparse and inexible. He displayed little capacity to elaborate

upon his thinking processes. For instance, when describing incidents that were confusing orthreatening to him, he often stated, “I thought it was strange.” However, he was not able toexpand upon his experience of strangeness , struggling with therapist questions such as “Whenyou say strange what do you mean?” or “What about it felt strange ?” So the therapist optedinstead for gentler reections consistent with Clancy’s reective capacity at the time, for instance,“Things didn’t feel quite right to you.”

During this phase of treatment, Clancy displayed signicant difculties understanding andexpressing emotional experiences. Painful emotions tended to trigger somatic concerns or perse-cutory ideation, which often derailed the therapy dialogue. In a bid to reduce Clancy’s sense of threat and maintain dialogue, the therapist avoided emotion-laden questions and reections inthe initial stages of treatment. Avoiding affect-laden probes appeared to assist Clancy to reveal

parts of himself at a pace that was nonthreatening.

Seven months into treatment: Enhancing metacognitive capacity and enrichingnarratives. Despite notable metacognitive decits, glimpses of Clancy’s desire to better un-derstand his difculties were evident during this phase of the intervention (phases 3 and 4 of the manual). Around 7 months into the treatment (session 23), Clancy began to reveal somemore complex affective experiences, and a clearer narrative around his experience of his illnessstarted to form. Specically, Clancy spoke of feeling like a “guinea pig” and “experimentedupon” when receiving hospital treatment for his psychosis. He acknowledged for the rst timethat the therapy sessions and relationship with the therapist were important to him.

The rst year of psychotherapy (43 sessions) was very much a process of trial and error, in

which the therapist was carefully testing the effectiveness of her interventions and adjusting herapproach in response to Clancy’s demonstrated reective capacity. The challenging nature of this stage of treatment cannot be overstated, and it may account for some clinicians’ reluctanceto engage in longer term therapy with people with psychosis.

The therapist reported feelings of hopelessness, frustration, and intense boredom that, in turn,led to some self-recrimination. That is, the experience of working with Clancy was quite differentthan the experience of working with people with a range of more common adjustment problems.She would also frequently nd herself with literally nothing to say in response to Clancy’s stories.Her internal dialogue would cease and her mind would be blank. This experience was potentiallyproblematic as a therapist with nothing to say is rarely effective. However, the experience wasalso informative.

Through supervision the therapist was able to reect on what it must be like to have a de-pleted inner world. With this understanding, the therapist was able to use her own experiencesin session to guide treatment, share aspects of her experience with Clancy, and further pro-mote the therapy relationship and dialogue: “Sometimes when we are talking I nd it hardto think of anything to say. I wonder if you ever feel like this.” Clancy responded with, “Yes!Before I come to session I think about the things I want to talk about. But when I get inthe room it’s like it all goes away; I’m blank.” Interventions such as this provided a sense of being in it together, sharing the experience of “blankness.” This seemed to provide Clancywith a strong sense of being understood and also allowed him to further explore his innerexperiences.

As treatment progressed, Clancy’s capacity to reect upon his mental states grew. Over time,

the therapist gained a better understanding of which interventions facilitated reection andwhich triggered an increase in psychotic material. Interventions that involved simple reectionsof Clancy’s mental states and the therapy process in the moment tended to be the most helpful;for example: “It’s hard for you to think of anything to say to me today”; “You’re thinking aboutX a lot at the moment. It is hard to think about anything else”; and “You were worried that Iwouldn’t be at our appointment today.” Open and vague questions, such as “How was that for


7/11


you?” or “How did you feel about that?” rarely facilitated the therapy dialogue and often leftClancy confused, resulting in disorganized, tangential responses.

At 15 months into therapy, a pivotal point was reached. Clancy revealed that his sibling wasdying of cancer. Contemplating the loss of his sibling seemed to open the door to exploring otherlosses and the associated painful affect. Over a series of sessions, loss and loneliness emerged as

signicant themes.During session 67, Clancy revealed a greater awareness of his illness experience and the effect

it has had on his life. He began demonstrating an increased capacity to reect upon his mentalstates and the therapeutic relationship. A more elaborate picture of who Clancy was in relationto his illness and others was developing.

Clancy: What do you want me to talk about?Therapist: It’s hard to think of something to talk about?

C: Yeah, I think that I’m having trouble. I’m thinking of the past all the time, yeah,politics and things like wars and things.

T: So things from the past have been on your mind a lot recently.C: I don’t know why, you know, I think it links to . . . oh, seeing as I’m 67 it’s pretty hard

to . . . ‘cause I’m single, never married. I don’t know other people in this position.Someone at my age would’ve been married long ago, you know. Since I’ve, I’m, youknow, I was sick all the time . . . . Sometimes I get ideas in my mind . . . . Oh, rememberI was talking to you about the Mormons a couple of weeks ago? Perhaps that was abit too much, you know, to relate to.

T: You’re worried about sharing certain ideas with me.C: Yes.T: That it’ll be too much.C: Well, they are schizophrenia, I suppose. Aren’t they related to it? You gotta talk about

it. But I feel a bit strange telling you, you know.T: So when you say you feel strange telling me, what’s that feeling like?C: Once I start I’ve gotta keep going . . . . It seems like I imagine a lot of it . . . . My

schizophrenia and my position . . . it’s dawning on me now, you know. So that’s itfor everything, you know, just go to mass and wait to die.

T: When you say it’s dawning on you, what’s dawning on you?C: The effect, the isolation. That’s about all, you know . . . I had jobs, weren’t very nice,

they were low paid jobs, you know.T: So the impact that schizophrenia has had on your life is dawning on you.C: Yes, yes.T: You said something interesting . . . you will just give up on everything and just go to

mass and wait to die.C: [laughs] I said yeah but I don’t know. I do painting. I exercise. Try to get as much

mental treatment as I can.

With the end in mind: Living enriched narratives. During the nal phase of treatment(phase 5 of the manual), Clancy was encouraged to take what he had learned within the therapyrelationship and apply it to his everyday life. For instance, Clancy was encouraged to exploreopportunities to connect with others in the community to address his loneliness. As therapy wascoming to an end, Clancy revealed that he would often recall the therapist’s voice reassuring

and guiding him when he was feeling unsafe. It seemed that over the course of treatment Clancyhad internalized the therapy dialogue. It was clear that therapy had become an important partof Clancy’s life. With this in mind, the end of therapy was carefully planned and spoken aboutthroughout this phase of the treatment. The nal session was surprising because Clancy seemedto have gained condence and expressed overt anger towards the therapist about the therapyending. At his request he was referred to a private psychologist so he could continue therapy.


8/11


Figure 1. Changes in reective capacity and symptom severity over the course of psychotherapy.

Outcome and Prognosis

Treatment progress was assessed using the MAS, BPRS, and qualitative data. MAS and BPRSratings were completed for interviews at pretreatment, 6 months, 12 months, and end of treat-ment (Indiana Psychiatric Illness Interview; Lysaker, Clements, Plascak-Hallberg, Knipscheer,& Wright, 2002). MAS ratings were also completed for sessions 9, 23, 38, 45, 52, and 67. A grad-ual, nonlinear improvement in Clancy’s metacognitive capacity over the course of treatment wasevident (see Figure 1). A gradual reduction in symptom severity overtime was also found, withClancy moving from the “markedly ill” range to the ‘moderately ill’ range on the BPRS (seeFigure 1).

Qualitatively, Clancy developed a more complex understanding of himself and his experi-

ences over the course of therapy. Although he continued to experience some symptoms andsocial isolation, he developed a greater capacity to manage these experiences and was moreactively pursuing a “social life.” He presented to emergency services far less frequently for anx-iety and somatic concerns. We took the view that Clancy would have beneted from ongoingpsychotherapy based upon metacognitive narrative principles and the opportunity to continueto develop his sense of self within a therapeutic relationship.

Clinical Practices and Summary

The dominant models guiding the work with patients presenting with schizophrenia draw uponbiological approaches citing evidence of a genetic predisposition and biological correlates. Nev-

ertheless, antipsychotic medication is rarely sufcient to enable patients with schizophrenia tofunction effectively and achieve meaningful degrees of recovery. Psychological approaches arecrucial in fostering recovery within this population. The current case study provides practice-based evidence supporting a metacognitive narrative approach to working with individuals whopresent with symptoms of schizophrenia.

We outlined a framework for conceptualizing schizophrenia as essentially a self-disorderand provided a basis for interventions aimed at bolstering human capacities for reection,narration, and meaning making. The implications to be drawn from the study are as follows:(a) people diagnosed with schizophrenia are willing to engage in a longer term psychotherapyand nd it benecial; (b) treatments tailored to the whole person, taking into account theirstrengths and decits, facilitate patient engagement; and (c) psychological interventions targeting

metacognitive capacity promote recovery in people with schizophrenia.By providing a therapeutic environment that is supportive and engages with the subjectiveexperience of the person, people with schizophrenia, in our experience, are enthusiastic aboutengaging in psychotherapy. Our experience has taught us that given the opportunity and a senseof openness on the part of the therapist, patients are cautious but equally motivated to engagewith others. A structured approach that is cognizant of the unique needs of the patient provides


9/11


a foundation for working psychotherapeutically with people with schizophrenia. Within thisframe, we are able to learn about the potential of the person to develop more integrated andcomplex ideas about themselves and others over the course of a systematic therapy process.The case of Clancy illustrates the potential of those most disabled by psychosis to develop agreater awareness of themselves and achieve meaningful degrees of recovery. It also points to the

importance of a more open attitude to the role of psychological interventions in the treatmentof people with chronic schizophrenia.

A number of factors helped promote Clancy’s metacognitive capacity and recovery over thecourse of therapy. First, the therapy relationship was considered paramount. The therapist wasnot afraid to focus on the intersubjective nature of the therapy and “deal with” the relationship:“What is it like talking to me about these ideas?” and “ You feel more comfortable with methan you used to.” The relational aspects of the treatment were made explicit in a bid todemystify social interactions and explore Clancy’s sense of confusion in relation to others.Second, Clancy’s subjective experiences were respected and given priority, with interventionsdesigned to illuminate his inner world: “ You think/wish/feel . . . ” and “What was that like for you?” The therapist also used her own subjective experiences in sessions to inform treatment.

Finally, the MAS-A was used regularly to assess changes in Clancy’s metacognitive capacitywithin sessions and over the course of treatment. Regular MAS-A ratings helped guide treatmentand ensured interventions targeted specic areas of decit.

Although the early evidence for Metacognitive Narrative Psychotherapy is promising, thereis a need to develop and implement large-scale trials, which are designed in response to theneeds of people suffering with psychotic disorders. There is also a need for increased trainingand support for clinicians who are motivated to provide longer term therapy for this patientgroup. We are hopeful that, over time, we will gain increasing evidence for the effectiveness of the intervention pioneered by Lysaker and colleagues and be better able to assist people withschizophrenia achieve meaningful degrees of recovery and live more enriched lives.

Selected References and Recommended Readings

Bargenquast, R., & Schweitzer, R. D. (2013a). Enhancing sense of recovery and self-reectivity in peoplewith schizophrenia: A pilot study of Metacognitive Narrative Psychotherapy. doi:10.1111/papt.12019

Bargenquast, R., & Schweitzer, R. D. (2013b). Metacognitive Narrative Psychotherapy for people di-agnosed with schizophrenia: An outline of a principle-based treatment manual. Psychosis, 1–11.doi:10.1080/17522439.2012.753935

Buck,K. D., & Lysaker, P. H. (2009). Addressing metacognitive capacityin thepsychotherapy forschizophre-nia: A case study. Clinical Case Studies, 8(6), 463–472. doi:10.1177/1534650109352005

Davidson, L. (2003). Living outside mental illness: Qualitative studies of recovery in schizophrenia. NewYork: New York University Press.

Dimaggio, G., Semerari, A., Carcione, A., Nicol ¯ o, G., & Procacci, M. (2007). Psychotherapy of personalitydisorders: Metacognition, states of mind and interpersonal cycles. New York: Routledge.

Estroff, S. E. (1989). Self, identity, and subjective experiences of schizophrenia: In search of the subject.Schizophrenia Bulletin, 15(2), 189–196. doi:10.1093/schbul/15.2.189.

Geller, J. D., & Farber, B. A. (1993). Factors inuencing the process of internalization in psychotherapy.Psychotherapy Research, 3, 166–180.

Lysaker, P. & Lysaker, J. (2002). A typology of narrative impoverishment in schizophrenia: Implicationsfor understanding the processes of establishing and sustaining dialogue in individual psychotherapy.Counselling Psychology Quarterly, 19(1), 57–68. doi: 10.1080/09515070600673703.

Lysaker, P. & Lysaker, J. (2002). Narrative Structure in Psychosis. Theory and Psychology, 12(2), 207–220.doi: 10.1177/0959354302012002630.

Lysaker, P. & Lysaker, J. (2008). Schizophrenia and the fate of the self. Oxford: Oxford University Press.Lysaker, P., Buck, K., Taylor, A. & Roe, D. (2007). Associations of metacognition and internalized stigma

with quantitative assessments of self-experience in narratives of schizophrenia. Psychiatry Research, 157,31–38. doi: 10.1016/j.psychres.2007.04.023.


10/11


Lysaker, P., Dimaggio, G., Buck, K., Carcione, A. & Nicolo, G. (2007). Metacognition within narrativesof schizophrenia: Associations with multiple domains of neurocognition. Schizophrenia Research, 93,278–287. doi: 10.1016/j.schres.2007.02.016.

Lysaker, P., Carcione, A., Dimaggio, G., Johannesen, J., Nicolo, G., Procacci, M. & Semerari, A. (2005).Metacognition amidst narratives of self and illness in schizophrenia: Associations with insight, neu-

rocognition, symptom and function. Acta Psychiatrica Scandinavica, 112, 64–71. doi: 10.1111/j.1600-0447.2005.00514.x.Lysaker, P., Glynn, S., Wilkniss, S.& Silverstein, S.(2010). Psychotherapy and RecoveryFromSchizophrenia:

A Review of Potential Applications and Need for Future Study. Psychological Services, 7(2), 75–91. doi:10.1037/a0019115.

Lysaker, P., Buck, K. & Roe, D. (2007). Psychotherapy and Recovery in Schizophrenia: A Proposal of Key Elements for an Integrative Psychotherapy Attuned to Narrative in Schizophrenia. PsychologicalServices, 4(1), 28–37. doi: 10.1037/1541–1559.4.1.28.

Lysaker, P. & Lysaker, J. (2011). Psychotherapy and Recovery from Schizophrenia: A Model of Treatmentas Informed by a Dialogical Model of the Self Experience in Psychosis. Journal of ContemporaryPsychotherapy, 41, 125–133. doi: 10.1007/s10879-010-9157-x.

Lysaker, P., Davis, L., Eckert, G., Strasburger, A., Hunter, N. & Buck, K. (2005). Changes in NarrativeStructure and Content in Schizophrenia in Long Term Individual Psychotherapy: A Single Case Study.Clinical Psychology and Psychotherapy, 12, 406–416. doi: 10.1002/cpp.457.

Lysaker, P., Clements, C., Plascak-Hallbert, C., Knipscheer, S. & Wright, D. (2002). Insight and PersonalNarratives of Illness in Schizophrenia. Psychiatry, 65(3), 197–206. doi: 10.1521/psyc.65.3.197.20174.

Lysaker, P. H., Buck, K. D., Carcione, A., Procacci, M., Salvatore, G., Nicol ò, G., & Dimaggio, G. (2011).Addressing metacognitive capacity for self reection in the psychotherapy for schizophrenia: A con-ceptual model of the key tasks and processes. Psychology and Psychotherapy: Theory, Research andPractice, 84(1), 58–69. doi:10.1348/147608310x520436

Lysaker, P. H., Buck, K. D., & Hammoud, K. (2007). Psychotherapy and schizophrenia: An anal-ysis of requirements of individual psychotherapy with persons who experience manifestly barrenor empty selves. Psychology and Psychotherapy: Theory, Research and Practice, 80(3), 377–387.

doi:10.1348/147608306x159361Lysaker, P. H., Buck, K. D., & Ringer, J. (2007). The recovery of metacognitive capacity in schizophrenia

across 32 months of individual psychotherapy: A case study. Psychotherapy Research, 17(6), 713–720.doi:10.1080/10503300701255932

Salvatore, G., Procacci, M., Popolo, R., Nicolo, G., Carcione, A., Semerari, A., & Dimaggio, G. (2009).Adapted metacognitive interpersonal therapy for improving adherence to intersubjective contexts in aperson with schizophrenia. Clinical Case Studies, 8(6), 473–488. doi:10.1177/1534650109354916

Sass, L. A., & Parnas, J. (2003). Schizophrenia, consciousness, and the self. Schizophr Bull, 29(3), 427–444.Semerari, A., Carcione, A., Dimaggio, G., Falcone, M., Nicol ò, G., Procacci, M., & Alleva, G. (2003). How

to evaluate metacognitive functioning in psychotherapy? The metacognition assessment scale and itsapplications. Clinical Psychology & Psychotherapy, 10(4), 238–261.


11/11

C o p y r i g h t o f J o u r n a l o f C l i n i c a l P s y c h o l o g y i s t h e p r o p e r ti t s c o n t e n t m a y n o t b e c o p i e d o r e m a i l e d t o m u l t i p l e s i t e s oc o p y r i g h t h o l d e r ' s e x p r e s s w r i t t e n p e r m i s s i o n . H o w e v e r , a r t i c l e s f o r i n d i v i d u a l u s e .

Documents

Capacidad Reflexiva en Esquizofrenia