ARTICLES
Metacognitive Reflection and Insight Therapy (MERIT)
Among People With Schizophrenia: Lessons From
Two Case Studies
Nitzan Arnon-Ribenfeld, M.A., Rachel Bloom, M.A., Dana Atzil-Slonim, Ph.D, Tuvia Peri, Ph.D, Steven de Jong, M.A.,
Ilanit Hasson-Ohayon, Ph.D.
People with schizophrenia spectrum disorder face a major
challenge in the ability to reflect on their own and others’
mental activities and about specific psychological problems
in their lives. These deficits are associated with increased
symptoms and lower functioning. Specific interventions have
been designed to enhance these abilities, one of which is
metacognitive reflection and insight therapy (MERIT). Sev-
eral case studies and a recent pilot study have shown in-
creased metacognitive abilities and a decrease in symptoms
among clients after MERIT. This article presents two case
Studies have found that people with schizophrenia and other
severe mental illnesses experience challenges in the ability
to reflect on their own and others’ mental activities and in
thinking about specific psychological problems in their lives
(1–3). The types of difficulties these clients have involve a
deficit in the capacity to “think about thinking” and “know
about knowing”—a deficit in what is broadly conceptualized
as metacognition (4). Various definitions of metacognition
exist in the literature. For example, Wells and Purdon (5)
define metacognition as a multifaceted function responsible
for the various roles of information processing “that moni-
tors, interprets, evaluates, and regulates the contents and
processes of its organization.” Carcione and Falcone (6)
propose that metacognition consists solely of the ability to
understand mental states for the purpose of using them to
cope with problems that are a source of subjective distress.
A more recent definition defines metacognition as including
a wide range of abilities that enable one to perform an on-
going construction of integrative and holistic representations
of the self and other (7, 8).
Accordingly, metacognition is viewed as including a wide
range of activities, ranging from discrete activities, in which a
person creates an idea about a specific thought or emotion,
to more synthetic activities, in which a person forms these
distinct thoughts into a complex representation of her- or him-
self or another person (8, 9). Studies that assess metacognition
according to this definition typically use the Metacognition
Am J Psychother 71:4, December 2018
studies of clients diagnosed with schizoaffective disorder
whose psychotherapy, conducted in Israel, incorporated the
MERIT protocol. Outcome measures were taken before and
after treatment, and metacognitive abilities were assessed at
five time points throughout treatment. Clinical implications
and limitations are discussed.
Am J Psychother 2018; 71:175–185;
doi: 10.1176/appi.psychotherapy.20180037
Assessment Scale-Abbreviated (MAS-A), which includes
measures of self-reflectivity, understanding the mind of the
other, decentration, and mastery, as discussed later (10–12).
In schizophrenia spectrum disorder, these deficits in
metacognition are described as being stable over time and are
assumed to be traitlike (13). However, studies have demon-
strated that the degree to which these deficits are experi-
enced varies across situations depending on the cognitive and
emotional demands of each situation (14, 15). Moreover, these
deficits have been linked to a greater level of psychosocial
deficits (7), pose a risk factor for negative symptoms (16), are
associated with increased positive symptoms (17), and are
linked to impaired social and vocational functions (18, 19).
Deficits in metacognitive abilities may also cause social
alienation by making it more difficult for people to form social
bonds or seek support from others (20, 21).
As the interest in conceptualizing and studying meta-
cognition has grown, several psychotherapies targeting
metacognition have grown out of their respective therapeutic
orientations. For instance, metacognitive therapy (22) and
social cognition and interaction training (unpublished
2006 manuscript by Roberts, Penn, and Combs) approach
metacognition from a more cognitive-behavioral framework,
using sessions to reframe clients’ thinking about their own
thoughts and associated problems, whereas mentalization-
based treatment (23) has a distinct psychodynamic overtone.
Relevant in this context may be the claim that people who are
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exploring their own difficulties and accepting them with self-
compassion may benefit from refining their metacognitive
abilities (24, 25). The tendency to accept one’s own diffi-
culties and to be understanding toward oneself when faced
with personal failures is conceptualized as self-compassion.
It consists of three core components: self-kindness, com-
mon humanity, and mindfulness (26). The literature re-
garding self-compassion has found associations between this
construct and psychological well-being; individuals with
higher levels of self-compassion have lower levels of stress
and psychopathological symptoms (27–29). Among people
with schizophrenia spectrum disorder, higher self-compassion
scores were associated with fewer negative and positive
symptoms (30). Similarly relevant in this context may be that
more integrative forms of cognitive-behavioral therapy for
persons diagnosed as having a psychotic disorder have started
to include elements from frameworks such as acceptance and
commitment therapy (31). The hope is that with increased
self-reflectivity (i.e., meta-cognitive ability), individuals will
develop a richer view of themselves that will include more
self-compassion.
Although several existing psychotherapies draw strongly
on a certain theoretical orientation of the therapist, MERIT is
an attempt at an integrative psychotherapy that can be in-
corporated by clinicians into their existing practice via eight
elements (discussed later). Using these eight elements, the
therapist assists persons diagnosed as having a psychotic
disorder or other serious mental illness to reflect on their own
mind and those of others in an attempt to pave the way for a
more synthesized understanding of mental states (32). One
therapy goal is to enhance the ability to deal with life challenges
using such mental state inferences. Several case studies have
illustrated that MERIT is accepted by clients, that it may
enhance metacognitive abilities, and that it may improve
functioning (32, 33), even among clients with symptoms that
are typically difficult to treat, such as severe disorganization
(34) and negative symptoms (35). A randomized controlled trial
of MERIT is currently underway in the Netherlands (36).
In this article, we present two case studies in which
psychotherapy incorporated MERIT, and we explore the
link among metacognitive abilities, global distress, and self-
compassion. The assessments of global distress and self-
compassion were performed using objective self-report
measures taken before and after treatment. Metacognitive
abilities were coded at five time points throughout therapy, in
equal intervals for each client, to track changes throughout
treatment.
CASE STUDIES
Clients and Treatment
The two clients described in this article were recruited
from a pool at a community university clinic at Bar-Ilan
University, Ramat-Gan, Israel. Therapy was conducted
between November 2015 and July 2016, according to the
academic schedule, so that the therapy endpoint was
176 psychotherapy.psychiatryonline.org
predetermined. These clients were chosen for this study from
a larger sample of clients according to the criteria of a di-
agnosis of schizoaffective disorder, according to the DSM-IV-
TR, and treatment length of 25–35 sessions. The study proce-
dures and test battery were part of usual care in the clinic for both
clinical and research purposes. Individual psychotherapy
consisted of weekly sessions that lasted 50 minutes each.
Treatment was based on the MERIT protocol, which was
applied in an integrative psychotherapy that included dynamic
exploration and the implementation of cognitive-behavioral
therapy techniques when needed. This integrative approach
is based on recent recommendations for the treatment of
schizophrenia (37). Therapists (NAR and RB) were doctoral
students in the clinical rehabilitation program of the Bar-Ilan
University psychology department. Each therapist received
one hour of individual supervision every two weeks and two
hours per week of group supervision. All therapy sessions were
audiotaped for use in supervision. The supervisor was a senior
psychologist (IHO), and the examination of treatment vi-
gnettes was structured to provide specific and direct feedback
to supervisees. The study was approved by the university
ethics committee.
MERIT Elements
MERIT involves eight elements, each of which facilitates a
different type of metacognitive reflection. The first element
is the client’s agenda, “attending to the client’s immediate
wishes and desires.” The therapist should be attuned to what
clients may be seeking and help them develop a greater
awareness of their wishes and intentions. Second is the in-
troduction of the therapist’s thoughts in ongoing dialogue;
taking care not to override the client’s agenda, the therapist
shares his or her thoughts about and perceptions of the client’s
activities and behaviors during the session. Next is narra-
tive focus, in which the therapist and client explore concrete
examples from the client’s life in the form of narrative de-
scriptions of events. The therapist attempts to facilitate a
greater awareness of (changes in) the client’s mental states.
The fourth element is the psychological problem, “at-
tending to [the client’s] sense of the psychological and social
challenges [he or she faces].” In this element, the psycho-
therapist and client recognize the psychological difficulties
experienced by the client and work together on the client’s
development of awareness of him- or herself as confronted
with specific emotional distress. Fifth is the element of re-
flection on interpersonal processes, or “attending to the
clients’ sense of how they are relating to the therapist.” The
therapist encourages the client to reflect on her or his re-
lationship with the therapist and to develop a greater
awareness of how the client is relating to the therapist. The
sixth element, perceptions of change, involves “the therapist
attending to the [client’s] sense of what [he or she is] expe-
riencing as it is happening within the session.” Reflection
on the sessions should help the client develop a greater
awareness of the client’s own experience of progress (or lack
thereof ) in therapy.
Am J Psychother 71:4, December 2018

The seventh element is optimal stimulation of reflections
about self and others. Using the anchor points of the MAS-A
(a metacognitive coding system described in the next sec-
tion), the therapist ensures the intervention matches the
client’s metacognitive capacity to stimulate the client’s at-
tainment of the next level of metacognitive functioning:
optimal stimulation of metacognitive mastery, in which the
therapist attends “to the client’s use of sense of self and others
to recognize and respond to psychological and social chal-
lenges.” By using interventions that are appropriate to the
client’s current metacognitive capacity, the client will de-
velop an increasing ability to use metacognitive knowledge
when responding to psychological and social challenges (38).
Outcome Measures
Outcome Questionnaire-45. Outcome Questionnaire-45 (OQ-
45; 39) is a 45-item self-report questionnaire designed to
measure changes among clients over the course of mental
health treatment. Clients are asked to rate their functioning
over the past week on a five-point Likert scale ranging from
0, never, to 4, almost always. The OQ-45 possesses adequate
test-retest reliability (0.84) and high internal consistency
(0.93; 40, 41). In this study, analyses revealed high internal
consistency both before (a=0.92) and after (a=0.79) treat-
ment in the original sample of 110 participants. Concurrent
validity has been demonstrated with a wide variety of self-
report scales (e.g., the Beck Depression Inventory). The
OQ-45 is widely used in mental health centers. The total
distress score has been shown to be sensitive to change (42).
Metacognition Assessment Scale-Abbreviated. The MAS-A
(17) is a coding system for different types of transcripts that
enables assessment of metacognitive abilities. It traces the
ability to produce a rich and integrative narrative of self and
others. The assessment is done using four subscales: self-
reflectivity, understanding the mind of the other, decentra-
tion, and mastery. Self-reflectivity and understanding the
mind of the other measure the capacity to form increasingly
complex representations of oneself or others. Decentration
measures the ability to take a nonegocentric view of the
mind of others and recognize that others’ mental state is
influenced by a range of factors. Mastery measures the ability
to recognize problematic internal states (e.g., distress) and to
respond and cope with psychological problems using in-
creasingly complex metacognitive knowledge (38). The
MAS-A scale is widely used to assess metacognitive abili-
ties; it has been found to be reliable and valid (13, 18, 17), and
scores have been shown to differentiate between persons
given a diagnosis on the psychosis spectrum and persons who
have no psychiatric diagnosis (43).
In this study, a doctoral student (NAR) in the clinical
rehabilitation program of Bar-Ilan University’s psychology
department, who was one of the therapists, coded the therapy
sessions after attaining satisfactory interrater reliability.
The rating was performed as in other case studies in
which therapist ratings were used (33, 44). The MAS-A
Am J Psychother 71:4, December 2018
ARNON-RIBENFELD ET AL.
reliability and validity have been demonstrated (17). For each
case study, five sessions were chosen and coded. The first and
last sessions were coded as a measure of metacognitive levels
before and after treatment. Three more sessions were chosen
at even intervals throughout the psychotherapy to track
metacognitive changes.
Self-Compassion Scale. The Self-Compassion Scale (SCS; 26)
is a 26-item scale that assesses six aspects of self-compassion:
self-kindness, self-judgment, common humanity, isolation,
mindfulness, and overidentification. Responses are given on
a five-point scale ranging from 1, almost never, to 5, almost
always. The SCS has an appropriate factor structure, with a
single overarching factor of self-compassion, and has demon-
strated predictive, convergent, and discriminant validity (26).
Procedure
Clients and therapists were asked to sign consent forms if they
agreed to participate in this voluntary study, and the clients
were told they could terminate their participation in the study
at any time without jeopardizing their treatment. The OQ-45
and the SCS were administered to clients as part of the intake
procedure (i.e., before treatment) and as part of the end-of-
treatment procedure (i.e., after treatment). Sessions were
audiotaped, transcribed, and then rated using the MAS-A.
TWO CASE PRESENTATIONS
Danny
Danny is a single man in his 50s, with a 20-year history of
schizoaffective disorder. At the time psychotherapy began, he
worked weekends in a coffee shop. He had a limited social
network and received rehabilitation services in his home;
these services involved a social worker, a psychiatrist, and
an employment guide. He was prescribed a routine dose of
antipsychotic medication and was symptomatically stable.
This was his third year in therapy and his first exposure to the
MERIT protocol.
History. Danny described his childhood as difficult; his family
was of low socioeconomic status, and he experienced severe
deprivation. His father used physical and verbal violence
toward him and his family. He described his relationship
with his mother as symbiotic. His mother died five years ago,
and he described her death as traumatic for him. Danny
described his relationship with his father as distant, and he
still views him as a violent and abusive man. Danny has two
sisters, and his relationships with both are ambivalent; on one
hand, he wants to be close to them, but on the other hand, his
sisters display a lack of interest in his life, which he links to his
mental illness. Their concealment of his mental illness makes
him feel disappointed, ashamed, and alienated from them.
During elementary school Danny preferred to be alone
and avoided socializing with his peers. At age 15, he began
to experience psychotic symptoms and voiced concerns to
which his family was unresponsive. Only three years later, at
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age 18, did Danny first receive psychiatric treatment, and he
was referred to a psychiatrist who prescribed him appro-
priate medication. Danny was drafted into military service
and met regularly with mental health practitioners. After
his term in the Army, he worked various jobs with the hope
of becoming financially able to leave his parents’ house and
move out on his own. He was motivated to do so by his strong
feelings of abandonment and solitude.
At age 30, Danny was hospitalized in a mental health
institution, at which point he was diagnosed with schizo-
affective disorder. After being hospitalized, Danny moved to
a community housing institution for people with severe
mental illness, and he was provided with work through a
government-run program assisting persons with mental ill-
ness to integrate into society. Danny has been hospitalized
several times in the past two decades. As in his childhood
and adolescence, Danny finds it difficult to create mean-
ingful platonic and romantic relationships in his adult life.
His few romantic experiences were a source of disap-
pointment; they left Danny with feelings of shame and re-
morse. He indicates never having experienced a healthy
relationship.
Metacognitive assessment. At the onset of therapy, Danny
was able to recognize that his ideas about himself and the
world around him are subjective and subject to change over
time. He could recognize that others have autonomous
mental functions and that he is not the center of other
people’s mental activities. In addition, he was able to de-
scribe his psychological challenges, which continue to be a
source of stress for him.
Course of treatment. At the beginning of treatment, Danny
expressed his expectations for the upcoming therapy and
shared details about previous therapeutic relationships and
therapy achievements. The therapist asked questions aimed
at helping Danny to develop greater awareness of his wishes.
His agenda seemed to be focused on improving his in-
terpersonal relationships as well as finding a partner. When
asked to answer questionnaires (as part of routine clinic
procedure), Danny found the questions upsetting and felt
frustrated with the therapist’s request that he answer them.
Danny and the therapist explored his strong reaction to the
questionnaires, first discussing the dialogue between them
before taking a narrative approach in which they explored
other episodes in which he had felt these intense emotions.
These reflections on himself and others helped them
to discover that Danny had previously felt insulted by
assessment; he felt it reduced him to numbers rather than a
whole (emotional) person. Together, the therapist and Danny
decided to forgo the questionnaires altogether, which in-
creased Danny’s trust significantly and allowed him to open
up in following sessions. The use of the second element
(therapist’s thoughts in dialogue) in this manner, in which
the therapist shared her thoughts and perceptions about
Danny’s behaviors during the session, encouraged Danny to
178 psychotherapy.psychiatryonline.org
reflect and helped him to develop a greater awareness of how
he relates to the therapist.
From the onset of therapy, Danny was overwhelmed by
interactions in his workplace. Despite his desire to talk about
other issues, such as interpersonal relationships, the dialogue
tended to shift back to issues regarding work. These some-
times contradicting agendas were confusing for the therapist,
who struggled with whether to direct the session to the
original agenda (i.e., finding a partner) or to focus on Danny’s
current difficulties. By concentrating on the first element of
MERIT (agenda), focusing on what Danny was seeking at the
present session, and the third element (dialogue), by sharing
her confusion in light of Danny’s contradicting agendas, the
therapist was able to help Danny develop a greater aware-
ness of his own wishes and intentions.
Danny described a significant difference between week-
ends and weekdays: an intensive overload during weekends
and no daily routine during the weekdays. The therapist and
Danny discussed the feelings of chaos he experienced at work
and the implications of these feelings for his life. During
sessions, in a joint effort, the therapist and Danny tried
to come to an understanding of which psychological prob-
lem underlaid his difficulties at his work. Danny described
feelings of social alienation, loneliness, and exploitation.
Reflecting on himself and others helped Danny develop a
better understanding of the social interactions in his work-
place. He came to realize that his expectations might not
always match what is possible in reality. He began to un-
derstand his difficulties in being aware of his feelings in the
present moment and expressing them. Thus, the psycho-
logical problem that was discovered was one of emotion
recognition and expression within interpersonal relation-
ships. This discovery enabled him to begin to respond to these
difficulties by seeking support from others. This enhance-
ment is illustrated in Figure 1 (time 2, time 3).
The psychological problem element proved instrumental
in Danny’s treatment. The joint reflection on and recogni-
tion of the psychological difficulties he experienced allowed
Danny to further develop his awareness and recognition of his
emotional distress. This deeper understanding of the source
of his distress made Danny decide to quit his job. Indeed,
when Danny announced this recognition, he reported feeling
a great sense of relief. This decision seemed to make Danny
regain a sense of mastery over his own life that followed his
increased self-awareness. After his resignation, Danny’s
stress level was reduced significantly, and he felt he was able
to focus on his agenda, interpersonal relationships. The use
of the first element (agenda) in this manner, in which the
therapist was attuned to Danny’s agenda and to the shifts in
his agenda between sessions, enabled Danny and his therapist
to focus on what Danny was seeking at the current session and
helped him to develop a greater awareness that his own
wishes and intentions could change. When the therapist
assisted him, however, in focusing on this wish, Danny grew
concerned, based on his past experiences, that he might get
caught up in an abusive relationship. By reflecting on
Am J Psychother 71:4, December 2018

interpersonal processes, the therapist and Danny determined
that he did not seem to perceive others as a source of support
for him. This perception was also expressed in his apparent
lack of interest in being supported and accompanied when he
had to have medical tests (routine checkup) performed,
Metacognitive abilities
which led to feelings of isolation because he felt he had no
one to turn to for help.
During this period, Danny reported increased symptoms
of social withdrawal, not taking care of his personal and
environmental hygiene, and persecutory thoughts and feel-
ings. Joint reflection with the therapist on these experiences
led to recognition of Danny’s difficulties in asking for help. To
address this issue, Danny contacted his psychiatrist and had
his medication adjusted. This change in medication lessened
the negative symptoms he was experiencing and provided
him with a sense of relief (“I did not realize how much I
suffered before”). This example highlights how joint re-
flections between the therapist and Danny led him to an
increased awareness of his own needs, which offered him a
stepping-stone to take agency in the form of requesting the
medical help he needed.
His medical tests raised fear of loss of independence and
concern that he would not be able to take care of himself in the
future. By exploring narrative episodes, the therapist and
Danny explored together how he felt during previous medical
tests, times in which his family supported him, and how this
support was experienced. His past negative experiences led
Danny to the understanding that he does not want his family
to accompany him to medical tests. By attending to Danny’s
wishes and desires, the therapist was able to help him develop
a greater awareness of his own wishes and intentions. In
search of support from persons other than his family, Danny
turned to his social worker. To his surprise, his request was
accepted. Danny used this exploration of narrative episodes
with the therapist (element 3, narrative focuses) to develop a
greater awareness of his mental states regarding the support
(or lack thereof ) he experiences. He then integrated this
information and used it to regain a sense of mastery over his
life, which in turn reinforced the idea that he could in-
dependently find the support he needed. During the course of
therapy, intense feelings toward his family arose again. By
reflecting on and exploring his emotions with the therapist,
Danny was able to understand that when he pushes away his
feelings, they tend to intensify. By reflecting about himself
and others and on interpersonal processes, Danny was able
to recognize and to express his feelings. This expression
was new and exciting for him, as he described: “Wow! We are
really getting to something here.”
Throughout psychotherapy and by reflection on sessions
with the therapist, Danny was able to develop a greater
awareness of his own experience. Danny described a social
event during which he realized how his point of view of
himself and others had changed, noticing how his perspective
had changed as a result. Danny then spontaneously revisited
the topic of the research questionnaires at the clinic and
expressed that he would like to complete them as a means of
Am J Psychother 71:4, December 2018
ARNON-RIBENFELD ET AL.
FIGURE 1. Danny’s metacognitive abilities, as measured by the
MAS-Aa,b
7
6
5
4
3
2
1
0
Time 1 Time 2 Time 3 Time 4 Time 5
MAS-A-S MAS-A-O MAS-A-D MAS-A-M
a
Metacognitive abilities were coded at five equal intervals throughout
therapy to track changes during treatment.
b
MAS-A, Metacognition Assessment Scale-Abbreviated; S, self-reflectivity;
O, understanding other’s mind; D, decentration; M, mastery. Scores range
respectively from 0–9, 0–7, 0–3, and 0–9, with higher scores indicating
higher metacognitive ability.
marking his change and progress in therapy. He felt that
answering questions about his thoughts and feelings re-
garding different aspects of his life would increase his
awareness of the changes he was experiencing. This self-
awareness also arose in the context of his experience of social
interactions and the changes in the feelings he now felt dur-
ing social interactions throughout the treatment. Perhaps
as a result of the narrative focus on his past relationships,
he noticed that not only had his views on regular interac-
tions changed, but also his views on romantic relationships.
Danny was not always on time for his sessions and
demonstrated great self-criticism when he was late. When,
however, he was late for a session toward the end of therapy,
Danny broke this habit and demonstrated acceptance and
compassion toward himself. He was successful in articulating
his growth by using this example to highlight how his per-
spective had changed in this respect. The topic of separation
additionally surfaced as therapy was nearing its ending point.
The therapist and Danny discussed the different separations
Danny had experienced in his life, and he described that these
separations were hard for him and that he used to prefer to
simply disappear. Reflecting on this pattern, Danny expressed
feeling guilty for abandoning others and wanted to change it.
The end of therapy seemed like a good opportunity to ex-
perience a new way to separate, and indeed Danny attended
every session toward the end of therapy and was able to
reflect with his therapist on their mutual feelings during this
process.
Assessment of metacognitive progress and outcome. Danny’s
metacognitive abilities varied throughout psychotherapy
(Figure 1). During the final stages of therapy, Danny was able
to reflect on the sessions, and he demonstrated a greater
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METACOGNITIVE REFLECTION AND INSIGHT THERAPY AMONG PEOPLE WITH SCHIZOPHRENIA
awareness of his own experience of progress. Specifically, he
was able to pinpoint how his point of view had changed over
time. It was apparent that Danny had developed increased
flexibility in contemplating difficult life events. Although he
had previously viewed past relationships as entirely negative
and even abusive, he was now able to see the potential for a
healthy, nonabusive relationship in his future. Moreover, the
fear he felt about having a relationship with a woman
somewhat decreased. At the same time, Danny expressed his
disappointment that he was not currently in a romantic re-
lationship despite all these changes, but said he felt closer to
fulfilling his wish.
Samantha
Samantha is a single woman in her 50s with a diagnosis of
schizoaffective disorder. At the time psychotherapy began,
she worked in administration. She had limited social net-
works and received rehabilitation services in her home that
consisted of a social worker and psychiatrist follow-ups. In
terms of medication, she had been prescribed a routine dose
and was symptomatically stable. This was not her first ex-
posure to therapy, but it was her first experience in therapy
using the MERIT protocol.
History. Samantha described herself as a quiet child, isolated
and very imaginative. She had significant learning difficul-
ties at school that did not receive an adequate response.
This lack of responsiveness from her environment increased
her feelings of isolation and led her to feel a lack of support.
Samantha grew up with her parents and two sisters. She
described having a good relationship with her father, who
died when she was an adolescent. Samantha expressed great
longing for her father, a feeling that received no legitimacy
from her mother. Samantha described her mother as a ma-
nipulative and intrusive woman and their relationship as
complex. Regarding her relationships with her sisters,
Samantha described caring for them but having experienced
rejection from them, and they were not currently in touch.
Samantha was drafted into military service and served as an
administrator. After her Army service, she moved to her own
apartment and started to use substances. During this time, she
had her first psychotic episode and was subsequently di-
agnosed with schizoaffective disorder with significantly
disorganized symptoms. She was hospitalized several times
in mental health institutions, and since then she has been
treated with medication and received rehabilitation ser-
vices. Currently, Samantha lives alone and has no social
relationships.
Metacognitive assessment. At the beginning of treatment,
Samantha was able to recognize that the ideas she has about
herself and the world are subjective and subject to change
over time. She was able to recognize and distinguish be-
tween another person’s different cognitive operations and
her own and could recognize that others have autonomous
mental functions. Samantha was unable to form a nuanced
180 psychotherapy.psychiatryonline.org
idea about her affective mental states, nor was she able to
recognize her psychological challenges, which are a source
of stress for her.
Course of treatment. During the first couple sessions,
Samantha expressed that her loneliness and yearning to find
companionship were what consumed her most at that stage
in life. To understand what she and the therapist defined as
her psychological problem, Samantha and the therapist de-
termined that the difficulty she encountered in her quest to
find intimacy was rooted in her struggle to understand herself
and others. This problem was evident in the therapy room
as Samantha expressed confusion, disorganized speech, and
difficulties in reflecting on the therapeutic dialogue. One of
the core elements of MERIT is the joint search for the
psychological distress the client is experiencing, in a way that
can be mutually understood. The understanding of Saman-
tha’s psychological problem became more nuanced through
the exploration of her thoughts and by the therapist’s
sharing thoughts about Samantha’s behaviors during the
session (at Samantha’s level of metacognitive capacity for
self-reflectivity). The use of the fourth element (psycho-
logical problem), in which the therapist and Samantha fo-
cused on Samantha’s struggles, enabled Samantha to be
aware of her own emotional distress. This recognition was
enabled because her therapist was attuned to what she might
be seeking and helped her develop a greater awareness of
her wishes and intentions. This enhancement in Samantha’s
metacognitive abilities is illustrated in Figure 2 (time 2).
In the early phase of treatment, when a therapeutic re-
lationship with the therapist was still developing, Samantha
spoke freely about past and current issues. She shared her
emotional bewilderment with her mother as a child and spoke
about relationships in an associative manner. While discus-
sing these issues, it became evident that Samantha experi-
enced great confusion and uncertainty in understanding
others. This difficulty was also manifested in the therapeutic
relationship; Samantha expressed feeling not understood by
the therapist and at the same time seemed to use the ther-
apist’s confusion to feel in control of the session. For example,
she repeatedly asked the therapist personal questions about
her family status. In response to this, the therapist used
element 5 (reflection on interpersonal process) and shared
her experience and understanding of the interpersonal ex-
change (i.e., feeling tense as a result of the personal ques-
tions and suggesting that they gave Samantha feelings of
control and power). This self-disclosure by the therapist
enabled Samantha to reflect on her tendency to enjoy others
being afraid of her, led to increased closeness, and facili-
tated the therapeutic alliance. The use of self-disclosure by
the therapist has been suggested by Hasson-Ohayon (45) as
important in improving metacognition and alliance.
Despite the achievement of enhanced dialogue regarding
the therapeutic relationship during these stages of therapy,
Samantha experienced lack of direction and goals in the
therapy and thus frustration. This frustration, combined with
Am J Psychother 71:4, December 2018

the emotional upheaval experienced from discussing life
events and the mental energy needed to deal with emergent
difficulties, resulted in a brief dip in Samantha’s mastery level
(Figure 2, time 3). Samantha’s lack of direction and goals was
also confusing and frustrating for the therapist; she felt that
Metacognitive abilities
Samantha’s disorganization was an obstacle to treatment.
Thus, the therapist decided to work more closely with the
protocol, which allowed for a more stable therapeutic en-
vironment. Specifically, the therapist began referring to the
psychological problem and enabling joint reflection on it.
This was done by attuning herself to Samantha’s agenda
(what Samantha came to the session for) in a more directive
approach, which enabled them to keep on track and sustain a
goal-directed manner.
Because of Samantha’s difficulties in piecing together
aspects of her life and recalling her personal experience of
past events, the therapist was active in helping her chro-
nologically sequence life events and in orienting by applying
narrative focus. We previously noted that using a narrative
approach to therapy, that is, attempting to discuss concrete
life events rather than only abstract thought (e.g., discussing a
time when one was angry rather than discussing anger in
itself ), frequently causes the produced narratives to increase
in richness and complexity (46).
Samantha demonstrated a similar process: As the dyad
created order in her recollections of life events, she began to
remember more details. Her narratives began to be filled with
other persons who were involved and new details about the
setting. Consequently, this made it easier for her to con-
template and elaborate on her feelings about and thoughts on
the event while reflecting on herself and others, ultimately
deepening her sense of mastery and the ramifications of her
actions in given past and current events.
During the final stages of therapy, Samantha was able to
reflect on the sessions and was more aware of her own ex-
perience of progress and lack of progress in therapy. She was
able to see how her point of view regarding others had changed
and had greater flexibility, which made her feel a sense of
accomplishment. Samantha was able to identify and observe
her emotions and to integrate her thoughts and actions and
see how they interacted. In addition, Samantha had greater
flexibility in the way she saw others, especially men. Despite
these achievements, Samantha still had difficulty with
understanding social cues and, therefore, in dealing with
complex situations. She expressed her disappointment that
she did not reach her ultimate goal—finding relationships.
However, she was able to look forward and see the potential in
further treatment in hope of reaching this goal.
Assessment of metacognitive progress and outcome. Saman-
tha’s metacognitive abilities varied throughout psychother-
apy (Figure 2). As therapy progressed, Samantha became
increasingly able to recognize that her self-representation
was subjective and that her opinions might change. In par-
ticular, Samantha was able to reflect on her new perspec-
tive on how she conducts herself in interactions with the
Am J Psychother 71:4, December 2018
ARNON-RIBENFELD ET AL.
FIGURE 2. Samantha’s metacognitive abilities, as measured by the
MAS-Aa,b
7
6
5
4
3
2
1
0
Time 1 Time 2 Time 3 Time 4 Time 5
MAS-A-S MAS-A-O MAS-A-D MAS-A-M
a
Metacognitive abilities were coded at five equal intervals throughout
b
therapy to track changes during treatment.
MAS-A, Metacognition Assessment Scale-Abbreviated; S, self-
reflectivity; O, understanding other’s mind; D, decentration; M, mastery.
Scores range respectively from 0–9, 0–7, 0–3, and 0–9, with higher
scores indicating higher metacognitive ability.
opposite sex. She was able to recognize her difficulties in
interpreting social cues and the pervasiveness of her over-
arching generalizations of men. Moreover, she was now able
to successfully infer others’ mental states via communicative
attitude or behavior in social interactions.
Outcome Evaluation
The MAS-A, OQ-45, and SCS were administered before and
after treatment (Table 1). The reliable change index (RCI) for
the MAS-A, OQ-45, and SCS was computed according to
Jacobson and Truax (47), using previous data sets to obtain
the standard deviation and a coefficient for each measure.
Danny’s and Samantha’s metacognitive ability to understand
the other’s mind increased by the end of therapy. The RCI was
computed using the standard deviation (1.03) from a sample
of clients diagnosed with schizophrenia (48) and a coeffi-
cient (0.82) from another sample of clients diagnosed with
schizophrenia spectrum disorder (18), and it indicated a
significant change for both clients. In addition, Danny’s and
Samantha’s mastery metacognitive ability, the ability to re-
spond to and cope with psychological problems using
increasingly complex metacognitive knowledge, had also
increased by the end of therapy. The RCI was computed
using the standard deviation (1.19) from a sample of clients
diagnosed with schizophrenia (48) and a coefficient (0.91)
from another sample of clients diagnosed with schizophrenia
spectrum disorder (18), and it indicated a significant change
for both clients.
The OQ-45 showed that Samantha’s distress levels had
decreased. The RCI was calculated using the standard de-
viation (28.35) and a coefficient (0.934) from a sample of
clients with severe mental illnesses in inpatient psychiatric
psychotherapy.psychiatryonline.org 181
METACOGNITIVE REFLECTION AND INSIGHT THERAPY AMONG PEOPLE WITH SCHIZOPHRENIA

TABLE 1. MAS-A, OQ-45, and SCS scores before and after therapy clients’ metacognitive abilities. In the case studies presented
Danny Samantha here, both clients were preoccupied with interpersonal re-
Measure Before After (RCI)a Before After (RCI)
lationships, and their expressed agenda at the outset of
b
treatment was to form a meaningful romantic relationship.
MAS-A
S 5 6c 4.5 5c
However, the psychological problem underneath each
O 2 5 (4.85) 3 5 (3.24) agenda differed; Danny’s focus was on the expression of
D 1 1c 1 1c emotion in interpersonal relationships, and Samantha’s
M 2 6 (7.92) 1.5 6 (8.91) focus was awareness of her own wishes and emotions and
OQ-45d 92 100c 98 52 (4.34) understanding her chaotic inner experience. In addition,
SCSe 2 3.15 (3.32) 2.96 3.07c although the recognition of Danny’s psychological problem
a
RCI, Reliable change index was calculated according to Jacobson and Truax occurred in the first therapy sessions, the recognition of
(1991) using the formula of Bauer S, Lambert MJ, Nielsen SL: Clinical signif- Samantha’s psychological problem came later because of her
icance methods: a comparison of statistical techniques. J Pers Assess 2004; 82:
60-70. Values larger than 1.96 are considered significant. overwhelming emotions and disorganized symptoms. Thus,
b
MAS-A, Metacognition Assessment Scale-Abbreviated; S, self-reflectivity; O, for the therapist, understanding Samantha was much more
understanding other’s mind; D, decentration; M, mastery. Scores range, re- of a challenge than understanding Danny. Accordingly, at
spectively, from 0–9, 0–7, 0–3, and 0–9, with higher scores indicating higher
metacognitive ability. the beginning of the therapy Samantha’s therapist felt con-
c
ns. fused and had difficulty adhering to the MERIT elements.
d
OQ-45, Outcome Questionnaire-45. Scores range from 0 to 180, with higher However, when therapy progressed, and emotions and
scores indicating higher symptoms of distress, as well as difficulties in in-
terpersonal relationships and in general quality of life. thoughts were recognized, confusion decreased.
e
SCS, Self-Compassion Scale. Scores range from 1 to 5, with higher scores The differences between the clients can also be seen in
indicating higher self-compassion. their initial metacognition levels. Whereas Danny came to
therapy with a high level of self-reflectivity, accompanied by
a lower level of awareness of others and recognition of
care (49), and it indicated a significant change. The SCS psychological problems, Samantha came with a lower level
showed that Danny’s self-compassion levels increased. The of self-reflectivity and recognition of psychological prob-
RCI was calculated using the standard deviation (0.50) and lems, but with a higher level of awareness of others. After
a coefficient (0.76) from a sample of clients with affective MERIT, both clients’ ability to understand the other’s mind
or nonaffective psychotic disorder with a diagnosis of psy- and to cope with psychological problems using increasingly
chotic disorder (50), and it indicated a significant change. complex metacognitive knowledge increased beyond the
RCI.
The literature regarding change in psychotherapy em-
DISCUSSION
phasizes that although change can occur in a gradual and
This article presents two case studies of MERIT psycho- linear way, it can also occur in nonlinear ways, as has been
therapy with persons with schizoaffective disorder. It follows found among clients with differing psychopathologies (51).
previous case studies in the literature (32, 33) and a recently Although these patterns were not explored among clients
reported pilot study on MERIT (34). It adds to the current diagnosed as having schizophrenia spectrum disorder, it
literature by adding objective measurements of global distress might explain the nonlinear change in Danny’s and Samantha’s
and self-compassion, as well as five measurements of meta- metacognitive abilities, as seen in Figures 1 and 2. After
cognition throughout the course of psychotherapy. Using following a case for more than 32 months, other authors have
multiple time points for assessment allows for an in-depth found a particular stair-step pattern (52).
exploration of the process of change in metacognition. Suc- Regarding change from pretreatment to posttreatment
cessful application of the MERIT protocol requires the ther- measures, Danny’s self-compassion increased by the end of
apist to attempt to include eight specific therapist activities treatment. This finding is congruent with the current liter-
(elements) in each session and to use an understanding of the ature on self-compassion among persons with schizophrenia
client’s metacognitive function that is based on the MAS-A to spectrum disorder, in which associations have been found
select appropriate interventions during the session. Because between higher levels of self-compassion and lower levels of
metacognitive capacity fluctuates (upward, in a stair-step stress and psychopathological symptoms (30). Although we
manner) during sessions but also between sessions, the did not carry out an assessment of symptoms specific to
therapist flexibly adjusts interventions based on continuous schizophrenia in Danny’s case study, this finding is congruent
monitoring of the level of functioning. For instance, pre- with Danny’s reports throughout therapy regarding his
viously acquired gains in self-reflectivity may not appear in symptoms and routine medical care.
the following session or in a moment when client affect runs Another change in scores from pretreatment to post-
high. treatment was seen in Samantha’s global distress level. As
Therapy aims, as well as metacognitive abilities, differ reported in other case studies (32, 33), alongside the
among clients, highlighting the varied use of the MERIT enhancement of metacognitive abilities, Samantha’s global
protocol and the need to tailor specific interventions to distress decreased. In the current case study, this measurement

182 psychotherapy.psychiatryonline.org Am J Psychother 71:4, December 2018


was done using a self-report scale (i.e., the OQ-45). Samantha
initially presented as noticeably disorganized, over-
whelmed by her own emotions and a chaotic inner experi-
ence, for which she was seeking help. After MERIT, her inner
experience became less chaotic as she developed a better
understanding of herself and others. From the attachment
theory perspective, these metacognitive abilities are critical
to emotion regulation and self-organization (23). In addition,
it is important to consider the length of therapy. The current
case studies lasted for only nine months. Although changes
were observed in scores on the OQ-45 and the SCS, as well as
on two MAS-A subscales, longer treatment may be needed,
and a more comprehensive assessment battery may be
needed to see the positive effects of increased awareness and
metacognition.
Another important aspect of assessing change throughout
psychotherapy is the use of routine outcome monitoring. In
the current case studies, the clients were asked to complete
questionnaires as part of routine clinic procedure. Danny’s
emerging willingness to complete these questionnaires
during psychotherapy indicated his wish to increase his
awareness of the change he was experiencing. In recent years,
using research questionnaires as a part of routine outcome
monitoring has become relatively common. As summarized
in a meta-analysis, such assessment has several benefits (53).
One advantage is the detection of slight improvements ex-
perienced by clients and thus recognition of progress
throughout treatment (54). Although in this study clients
and therapists did not receive weekly feedback, by merely
answering questions about his thoughts and feelings re-
garding differing aspects in his life, Danny’s awareness of
the change he was experiencing throughout treatment may
have increased.
Limitations
The current case studies had several limitations. We de-
scribed the integration of the MERIT protocol and critical
elements in an integrative psychotherapy for two clients
with schizoaffective disorder. To provide a further basis for
MERIT’s effectiveness, additional studies with more rigorous
design, such as a randomized controlled trial, should be
carried out. Our case studies were relatively short term, and
we did not carry out follow-up measurements regarding
metacognitive abilities and symptoms. Therefore, how stable
the gains are over time is unclear. In addition, the assessment
of symptoms was not specific to schizophrenia. Notably, al-
though the advantage of these case studies is that they used
multiple assessment times, longitudinal randomized con-
trolled trials that use additional outcome measures may
provide more evidence of MERIT’s effectiveness. In addi-
tion, whereas the case studies included multiple times at
which metacognitive abilities were assessed, which en-
abled the tracking of changes throughout treatment, a gap
in the self-reflectivity ratings exists in comparison to the
case descriptions. Clients’ self-reflectivity ranged wider
than captured at the five assessment points throughout
Am J Psychother 71:4, December 2018
ARNON-RIBENFELD ET AL.
therapy. Perhaps more frequent measurements would have
better reflected these abilities.
Finally, the role of the therapist and her way of adopting
the MERIT protocol and her feelings and thoughts about it
were not the focus of these case studies. We assume that the
therapist’s reaction to the protocol and countertransference
issues played a major role in the therapy process (55) and,
therefore, should be the subject of future exploration.
Clinical Implications
Using the MAS-A to assess the client’s initial metacognitive
abilities and deficits provides a starting point at which the
therapist can select interventions to match the client’s cur-
rent metacognitive abilities. Throughout the course of ther-
apy, this assessment can change and, therefore, guide the
therapist to adjust to the client’s changing metacognitive
abilities and to modify interventions, respectively. Using the
MERIT protocol, the therapist helps the client to reflect on
his or her own and others’ minds, which subsequently allows
the client to form a better understanding of mental states and
to respond to challenges in a more flexible and adaptive way.
As with any therapy, the therapeutic alliance must be the basis
on which the therapist and the client agree on therapeutic
goals and develop a good relationship. The therapist and
client should explore metacognitive deficits together, and the
therapist should attend to the client’s immediate wishes and
desires and address the client’s personally defined goals.
AUTHOR AND ARTICLE INFORMATION
Department of Psychology, Bar-Ilan University, Ramat-Gan, Israel (Arnon-
Ribenfeld, Bloom, Atzil-Slonim, Peri, Hasson-Ohayon); Department of
Clinical Psychology, University of Amsterdam, Amsterdam (de Jong).
Send correspondence to Ms. Arnon-Ribenfeld (nitzanarnon2@gmail.
com).
This article is based on the first author’s doctoral dissertation, Depart-
ment of Psychology, Bar-Ilan University, Ramat-Gan, Israel. The study was
conducted with the support of an internal scholarship. The disserta-
tion was mentored by Dr. Ilanit Hasson-Ohayon and Dr. Dana
Atzil-Slonim.
The authors report no financial relationships with commercial interests.
Published online November 26, 2018.
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