Given the potential of psychotherapy to address subjective aspects of recovery by addressing both personal narrative and metacognitive capacity, one clear need for future research is the development of manualized treatments which could be tested for feasibility and effectiveness in randomized controlled trials. Following the illustration in , we envision this psychotherapy as addressing both narrative and metacognition deficits, conceptualizing them as interdependent. Without metacognitive capacity it should be difficult to evolve a complex storied understanding of one’s life, and without a sense that one’s life is worth telling a story about there should be little need for complex acts of metacognition. With regards to issues of narrative we would also envision this psychotherapy as addressing developing narratives as complex multilayered acts. The development of an enriched narrative for one person might not proceed in the same manner as for another, but in general this work should involve the simultaneous development of a number of semi-independent stories, including for instance, stories about personal challenges, aspects of life where competence was experienced, grief over losses, hopes for the future, and stories about how the present situation could evolve into the hoped-for future. Challenges and symptoms would need to be linked to personal life experience in a way that was both potentially consensually valid but also preserving of self-esteem, rather than attributing them exclusively to a biological illness and brain disorder.
Turning to the issue of metacognition, we would envision a psychotherapy that might promote recovery by providing a place in which clients may develop their capacities to think about thinking. This might well involve offering opportunities to practice acts of metacognition leading to the strengthening of the ability to perform metacognitive acts of increasing complexity. As discussed by Chadwick (2006)
, psychotherapy can provide many opportunities for this, in terms of examining and monitoring: 1) attributions regarding self and others; 2) symptoms and mental states; 3) schemata-linked habitual reaction patterns in thinking and behavior; and 4) thoughts and feelings about all parts of the self. And, as suggested by Buck and Lysaker (in press)
psychotherapy is thus one method in which different kinds of metacognition capacity are regularly assessed and intervention is accordingly staged to match client’s capacities.
The development and definition of such treatments would seem likely to be able to draw from a range of existing procedures and by definition be integrative in nature. For instance, cognitive behavior therapy for psychosis has been used to address the personal meaning of symptoms (Silverstein, 2007
) as well as awareness of the process of thinking beyond the correction of maladaptive beliefs (Davis & Lysaker, 2005
). The incorporation of methodologies which target metacognition in other groups (Bateman & Fonegy, 2001
; Fiore et al. 2008
) could also enrich and speed the process of definition and testing of such an intervention.
A related issue for future research regards the development of tools that could be used to assess changes in subjective sense of self. If psychotherapy can lead to change in personal narrative or metacognition how could this be reliably assessed? Certainly a range of relevant instruments exist, Resnick and colleagues (2004)
, for instance, have reported on the responses of over 800 persons to measures of life satisfaction, hope, knowledge about mental illness and empowerment and linked those with other aspects of outcome. Others have similarly linked other assessment of hope and internalized stigma to outcome as well (Wright, Gronfein & Owens, 2000
; Landeen, Seeman, Goering & Streiner, 2007
While these measures may produce estimates of beliefs relevant to self-experience, other efforts have also recently been undertaken to develop a recovery oriented scale to quantitatively assess self-experience as it is expressed in the personal narratives of persons with schizophrenia. One tool, the Scale to Assess Narrative Coherence (STAND; Lysaker et al., 2006
), can be used to rate the extent to which a coherent story of an individual person and their psychiatric challenges is present in spontaneously generated speech samples (e.g. from psychotherapy transcripts or semi-structured interviews). The STAND assesses specifically the extent to which persons portray themselves as possessing social worth, being connected to others, and having the ability to meaningfully affect their own destiny, elements closely tied to the SAMHSA principles of recovery. Evidence of inter-rater reliability, internal consistency and concurrent validity have been demonstrated across several samples of adults with schizophrenia in a post- acute phase of illness (Lysaker, Buck, Taylor & Roe, 2008
; Lysaker et al., 2006
). Davidson (2003)
noted that the earliest phases of recovery may involve struggling to fully accept oneself as a person whose story is worthy of being told. Roe and colleagues note that the later stages of recovery involve achieving mastery in the process of constructing and negotiating meaning (2006). The STAND may offer developing research on recovery oriented psychotherapy as a way to quantify movement along this most personal and subjective continuum.
Regarding assessment of metacognition, formal tests exist which assess different aspects of metacognition (Brune, 2005
). However, these instruments assess metacognition as cued within the laboratory, and were not developed to detect metacognitive capacity in speech samples such as those derived from psychotherapy sessions and clinical interviews (Lysaker et al., 2008
). As a result, paralleling the issue of narrative, efforts have also been undertaken to develop a scale that could rate the presence of metacognitive capacity from the same speech samples utilized to rate the STAND (e.g. from psychotherapy transcripts or semi-structured interviews). This scale, the Metacognition Assessment Scale (MAS; Semerari et al., 2003
) was originally designed to detect changes within psychotherapy transcripts in the ability of persons with severe personality disorders to think about their own thinking, and has since been modified for use as a dimensional scale. The MAS contains four scales which pertain to different foci of metacognitive acts: 1) the comprehension of one’s own mental states, 2) the comprehension of other individuals’ mental states, 3) the ability to see the world as existing with others having independent motives, and 4) the ability to work through one’s representations and mental states to implement effective action strategies in order to accomplish cognitive tasks or cope with problematic mental states. Individuals are assumed to possess varying capacities in each of these domains such that any given persons might be able to achieve more or less complex metacognitive acts in each of these scales.
Evidence of inter-rater reliability and validity of the MAS have been presented across several samples of adults with schizophrenia in a post acute phase of illness (Lysaker et al., 2007
; Lysaker et al., 2008
) as well as evidence that it measures different phenomena than does the STAND (Lysaker, Buck, Taylor & Roe, 2008
). Like the STAND, the MAS may offer future research on recovery-oriented psychotherapy a way to quantify movement along this most personal and subjective continuum.
Importantly, with the development of assessments of changes in narrative and metacognition, opportunities for other important practical and more theoretical avenues of research are likely to open. First, with future general empirical support for these procedures it will have to be determined what would assist clinical settings to implement such a form of psychotherapy. While SAMHSA and others frame recovery as a non-linear and certainly not necessarily a relatively short term process, what are the sorts of time frames within which change might be expected? Another set of practical issues to be addressed will also pertain to what forms of training and supervision are necessary to support them. For instance, what sorts of staff can learn and implement these procedures, and what staff and environmental variables determine whether the intervention is implemented faithfully?
Second, on a more theoretical note, while we have focused on self-experience as a meaningful domain of recovery in its own right, changes in this domain are likely to lead to changes in other domains of recovery. With new procedures and assessments of changes in self-experience, it may be possible to empirically examine the kinds of reciprocal relationships that exist between changes in the capacities for metacognition and the richness personal narrative with changes in functional assessments of work, interpersonal and community function. Such research would not only be of theoretical import in terms of conceptualizing the process of recovery but also to might help to develop and refine new treatments. Ultimately, such a program of research could be capable of exploring whether the kinds of psychotherapy described above have an effect on more internal and subjective constructs linked to recovery such as the extent to which one feels one is more in control of one’s choices, self-esteem, involvement in one's own recovery process, and feeling that one's life has meaning.
Consistent with this, as has been long noted, participation in a range of rehabilitative activities may reshape how one makes meaning of one’s life both in the immediate and larger narrative sense (Bell, Tsang, Greig & Bryson, 2007
; Harris et al., 1997
). Thus it seems important to study the psychotherapeutic effects of currently employed rehabilitative and other evidence-based methods which stress the benefits of natural supports. Does the acquisition of skills and the development of natural supports in other evidenced based programs have similar or different effects on personal narrative, cognition and social skills as psychotherapy? Such research may point to a way to further enhance the effects of these interventions with regard to narrative and metacognition. It may also point to important developments with regards to the interface of psychotherapy and other interventions and some promising avenues for synergistic combinations of interventions. For example, might not cognitive rehabilitation (to improve cognitive flexibility), for instance augment the possible impact of a recovery oriented psychotherapy leading to greater degree of improvement in the subjective domains of recovery? Similarly, given findings on the multiple positive effects and meanings of work for people with schizophrenia, might not supported employment help generate beliefs and feelings about the self that can be further explored and integrated with other aspects of personal narrative in psychotherapy (Roe, 2001
; Cook et al., 2005
Finally, future research is also needed to address for whom such forms of psychotherapy might be most useful. For instance are these interventions better suited for persons who are earlier vs. later on in their illness? Intuitively, given that persons early in the their illness have many difficult things to make sense of (i.e., the meaning of the psychotic episode in their life trajectory, whether it is an obstacle to overcome or evidence of inevitable decline, whether life dreams will be pursued or abandoned, etc.), and many troublesome decisions to reach, a therapy that addressed issues of narrative and metacognition might be uniquely useful. Of note, as suggested in one recent review, the usefulness of more symptom focused cognitive interventions is still a matter of debate (Morrison, 2009
). That said, it may also be that persons late in their illness may also have unique though somewhat different needs, including the mourning of dreams lost earlier in life due to illness as well as just the ravages of persistent disease and what is seen as possible for the remainder of life. Research has suggested the needs of older persons with schizophrenia are still not well understood and often go unaddressed (Karlin, Duffy, & Gleaves, 2008