1

Psychology and Psychotherapy: Theory, Research and Practice (2011), 84, 18 C 2011 The British Psychological Society

The British Psychological Society

www.wileyonlinelibrary.com

Editorial Introduction

Metacognitive disturbances in persons with severe mental illness: Theory, correlates with psychopathology and models of psychotherapy
Paul H. Lysaker1,2 , Andrew Gumley3 and Giancarlo Dimaggio4
1 2

Roudebush VA Medical Center, Indianapolis, Indiana, USA Indiana University School of Medicine, Indianapolis, Indiana, USA 3 Centre for Population and Health Sciences, University of Glasgow, Scotland 4 Terzo Centro di Psicoterapia Cognitiva, Rome, Italy
Metacognition refers to the ability to think about thinking, both ones own and that of others. In this introduction to the special issue on this subject, the editors summarize preceding literature on the nature and extent of metacognitive disturbances in severe mental illness. They then summarize the proceeding seven pieces that explore models of metacognitive disturbance in severe mental illness, its correlates with psychopathology, and emerging models of psychotherapy.

The range of what we think and do is limited by what we fail to notice. And because we fail to notice, there is little we can do to change, until we notice how failing to notice shapes our thoughts and deeds. R.D. Laing

Although there is a long history of thinking about thinking in psychology and psychiatry, it is since the late 1970s that theoreticians and researchers from widely varying traditions and disciplines have described the sets of mental activities involved in thinking about thinking as falling under the general label of metacognition (e.g., Flavell, 1979). Interest in metacognition has emerged in the face of evidence that human beings do not merely process information or solve problems. How we as human beings create and co-create meanings has a large impact on how we process and manage the world around us as well as upon our internal worlds. To think about thinking is not merely an unusual artefact of cognition but a uniquely human capacity, which is necessary for successful adaptation to a changing social world. It is our evolved ability to attune to and share our own mental states and the mental states of others, which enables the creation of
Correspondence should be addressed to Dr. Paul H. Lysaker, Roudebush VA Med Center (116H), 1481 West 10th St, Roudebush VA Medical Center, Indianapolis, Indiana 46202, USA (e-mail: plysaker@iupui.edu).
DOI:10.1111/j.2044-8341.2010.02007.x

Paul H. Lysaker et al.

afliation-based complex social systems that can respond to the ever evolving challenges of our environment (Hrdy, 2009; Liotti & Gilbert, 2011). Our interest in metacognition grew out of our desire to understand and respond to states of human distress that we see in our clinical practice. From this point of view, we have understood metacognition as a function of how individuals make sense of their own and others behaviour in terms of mental states and their utilization of this capacity to solve problems and to cope with specic mental states that are a source of distress (Semerari et al., 2003). Closely related to this is the work of Bateman and Fonagy (2004) who describe the closely associated construct of mentalization dened as the process by which an individual implicitly or explicitly interprets his own actions and those of others as meaningful on the basis of intentional mental states (e.g., desires, needs, feelings, beliefs and reasons) (page 302). Early work on metacognition offered unique insights into healthy function; it also pointed to the possibility that if these capacities were compromised, less healthy function would ensue. One of the rst clinical applications concerned autism. In particular, as has now been widely demonstrated, the profound inability to think about the mind of another person is a key explanatory factor in why children with autism struggle to relate to other people (Baron-Cohen, Leslie, & Frith, 1985). Following the early work on autism, interest grew steadily in the 1990s regarding the possible roles that decits in metacognitive capacity could play in adults with serious mental disorders. Frith (1992) proposed that an inability to recognize and make sense of mental states, both ones own and the mental states of others, was a core and stable decit in schizophrenia. This decit was proposed to provide a comprehensive neurobiologically based explanatory framework for the expression of symptomatology linked to schizophrenia. Fonagy (1991) proposed that persons with borderline personality disorder (BPD) experienced specic decits thinking about thinking in intimate interpersonal circumstances. These specic decits are hypothesized to explain the phenomenology of affect dysregulation and interpersonal dysfunction, which represents the core features of the disorder. Stiles and colleagues (1990) noted how persons with depressive disorders possessed a minimal awareness of disturbing thoughts and most importantly had a limited ability to describe affects. Since these initial proposals, research has increasingly suggested that decits in metacognitive function play a key role in the development of psychosocial dysfunction among adults with severe mental illness (Fonagy, Gergely, Jurist, & Target, 2002; Dimaggio & Lysaker, 2010; Dimaggio, Lysaker, Carcione, Nicol` , & Semarari, 2008; o Semerari et al., 2003). For instance, difculties managing relationships might be in part a direct result of difculties detecting and labelling the intentions of other people. Difculties responding effectively to feeling overwhelmed at work might result from an inability to recognize ones emotions and see ones own conclusions as subjective and fallible (Lysaker et al., 2010). The key point here is that the phenomenology of symptom expression in severe mental illness may be a reection of a core common pathway involving difculties in different aspects of metacognitive functioning. Evidence supporting this view includes ndings that decrements in the ability to think about thinking are predictive of compromises in work and social setting and that these decits may moreover mediate the effects of others aspects of illness such as decits in neurocognition upon outcome (Br ne, Abdel-Hamid, Lehmkmper, & Sonntag, 2007; u a Lysaker, Dimaggio et al., 2010; Lysaker, Shea et al., 2010). One response to this emerging knowledge has been a call to more carefully describe metacognitive problems and their antecedents as well as to develop psychotherapeutic

Metacognitive disturbances in severe mental illness

approaches to address these. For instance, it is not yet well established how these decits develop from childhood onward. The debate remains whether metacognition or its kin term Theory of Mind (ToM) develops as a result of xed and inborn maturational steps (German & Leslie, 2004) or whether the early interpersonal environment plays a key role in helping children to form nuanced understandings of mental states as they grow and develop (Fonagy et al., 2002). This question is also of relevance to adult psychopathology. On the one hand, impairments in mentalization have been shown to be closely linked to impairments in social and interpersonal functioning observed in schizophrenia. Frith (1992) proposed that mentalization develops adequately amongst individuals later diagnosed with schizophrenia and in line with the cognitive development of normal children, but that abnormalities in brain function and circuitry gave rise to specic abnormalities in meta-representation expressed as symptoms of schizophrenia. In this model, the role of the individual themselves in responding, shaping, and evolving adaptation and the inuence and constraints imposed by the context of their development was minimized. In contrast, Fonagy and Target (2006) have argued that the capacity for metacognition and mentalization evolves through the experience of social interaction and caregiving, and it has been hypothesized that early disruption of affectional bonds will increase the risk of later maladaptation through impaired mentalization. In this sense, mentalization is crucial to the maintenance of a coherent sense of self and acts as a buffer between early adversity on the one hand and later emotional and interpersonal adaptation on the other hand. Bateman and Fonagy (2004) have argued that in BPD there is an inhibition of mentalization where individuals will defensively avoid thinking about the mental states of self and others, as these are linked to experiences in the past (e.g., trauma and maltreatment) that have been associated with extreme pain. In this sense, there is a distinction between capacity for mentalization and utilization of mentalization. For those who have experienced trauma in the past and for whom capacity for mentalization is already weakened, the collapse of mentalization in the face of further stress (e.g., increased emotional arousal) leads to the loss of awareness and an inability to differentiate internal and external experiences. This results in extreme states of affect combined with dissociative responding, thus creating the affective and interpersonal instability, which characterizes BPD. There is a clear need to explore more fully these boundaries and distinctions in developing more comprehensive and nuanced metacognitive understandings of complex mental health problems, and how a greater understanding of the developmental and interpersonal origins of metacognitive functioning provide a pathway towards understanding symptom expression and course (Liotti & Gumley, 2009). Further, psychotherapy by its very nature offers rich opportunities for individuals to think about their own thinking. Holmes (2001) has likened psychotherapy to a playful pretend mode of functioning facilitated by the secure relationship with a therapist, which enables the exploration of real and imagined modes of function within interpersonal problems. From this viewpoint, metacognition provides a key framework to begin to understand mechanisms of change across a range of complex mental health problems (Dimaggio, Semerari, Carcione, Nicol` , & Procacci, 2007; Bateman & Fonagy, 2004; o 2009; Gumley & Schwannauer, 2006; Lysaker et al., 2005; Levy et al., 2006). One key issue is that, as a result of an impressive blossoming of research and theory during the last few years, metacognition can be conceptualized as a set of semi-independent functions (Baron-Cohen, 2006; Saxe, Moran, Scholz, & Gabrieli, 2006;

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Semerari, Dimaggio, Nicol` , Procacci, & Carcione, 2007; Whitehead, Marchant, Craik, & o Frith, 2009), which partially interact with each other, that can be selectively impaired in some disorders or interact together creating a toxic mixture impairing effective coping and problem solving during times of heightened emotional distress or in response to challenging social interactions (Dimaggio & Lysaker, 2010; Dimaggio et al., 2008; Dimaggio, Vanheule, Lysaker, Carcione, & Nicol` , 2009; Semerari et al., 2003). As an example, o poor awareness of ones own emotion is present in sub-samples of depression sufferers (Vanheule, Desmet, Verhaeghe, & Bogarets, 2007) and predicts poorer treatment alliance and worse outcome (Ogrodniczuk, Piper, & Joyce, 2005; in press). Some individuals with severe depression also have difculty in understanding others minds (Inoue, Yamada, Tonooka, & Kanba, 2004). As a result of these observations, treating individuals who are depressed should include an assessment of their metacognitive skills, tailoring treatment in order to let them rst promote increased emotional awareness (Beutler, Castonguay, & Follette, 2006), and then progressively forming a richer picture of themselves integrating more adaptive self-aspects. Turning to the eld of schizophrenia, empirical work is increasingly indicating that decits in metacognition have a deeply negative impact on social functioning in persons with schizophrenia (Lysaker et al., 2010). This indicates a need for psychological interventions aimed at improving the understanding the mental states of both oneself and others in order to help individuals adapt to complex social interactions and regulate distressing affect. With respect to those with a diagnosis of a psychotic disorder, there is evidence that focus on metacognitive functioning should be phase specic. Whilst there is evidence from individuals with long standing chronic psychosis that there are greater impairments in metacognition (e.g., Lysaker et al., 2005) and affect regulation (e.g., Dozier, 1990), MacBeth and colleagues (2011), in this issue, show that the patterns of metacognition do not show uniform impairment in those recovering from rst episode psychosis. This suggests that treatment approaches targeting metacognitive processes may differ in the early course (e.g., Gumley & Schwannauer, 2006) from the latter course (Lysaker, Buck, & Ringer, 2007). However, and importantly, both approaches share key goals in supporting individuals developing a more coherent and reective life narrative. More research evidence is required in the eld of personality disorder. There is growing acceptance that impairments in metacognitive functioning is a key and prominent feature of personality psychopatholology (Choi-Kain & Gunderson, 2008; Clarkin, 2008; Dimaggio et al., 2007; Fonagy, 1991; Livesley, in press; Jrgensen, 2010; Semerari et al., 2003). One well-established decit in this population is emotional awareness, which appears mostly as a feature of person with cluster C personality disorder (Nicol` et al., in press). The detailed knowledge of the possible different o decits in making sense out of mental states may help rene treatments according to the prole of metacognitive dysfunction (Dimaggio et al., 2007) or push other forms of treatment for personality disorder integrating techniques for improving metacognition in their manuals. Therefore, the current special issue of Psychology and Psychotherapy presents six papers that bear directly on these questions. In the rst piece, Liotti and Gilbert (2011) place metacognition within an evolutionary framework and in particular emphasize the importance of the attachment system in fostering the development of mentalization through creating the conditions for experiencing safeness. The evolution of mentalization and metacognition in humans might best be understood through different types of

Metacognitive disturbances in severe mental illness

social relating and their underpinning motivations. For example, metacognitive function in the context of afliative relating is linked to open attention, empathic attunement, and the creation of social safeness, which enables sharing, nurturance, expression of affect, curiosity, exploration, and playfulness. In contrast, in competitive-based social relating, metacognitive function provides context for focused attention including the anticipation of others intentions, sources of threat to ones own social rank, comparison with others, and sources of vulnerability or weakness in competitors. This important paper makes clear the fundamental relationship between evolved social mentalities and the way in which metacognition has evolved contrasting functions and utility within these distinctive mentalities. In the second piece, Lecours and Bouchard (2011) describe their approach to the verbal elaboration of affect (VEA) that emphasizes the assessment of the individuals capacity to represent and verbally articulate basic affective experiences. They describe how their approach to the assessment of VEA enables a more ne-grained analysis of different emotional topics and propose that this is important because of the ability to verbally articulate ones emotional experience. They show how greater verbalization of sadness is linked to lower levels of BPD symptomatology, whilst greater expression of hostility towards others is associated with higher levels of BPD symptoms. These ndings suggest that in their participants the externalization of hostility, perhaps through an inability to contain and reect on negative affect, may have important implications for understanding affect dysregulation in BPD. In the third piece, by MacBeth and colleagues (2011), we see the rst ever empirical report of reective functioning as measured by the Adult Attachment Interview (AAI: Main, Goldwyn, & Hesse, 2002) in a sample of individuals with psychosis. In addition, they also provide the rst report of the use of the AAI in such a sample of rst episode psychosis. Unlike previous studies of the AAI, which nds a dominance of insecure (largely dismissing) attachment states of mind in people with a diagnosis of Schizophrenia (Dozier, 1990), MacBeth and colleagues nd secure attachment classications within their sample. Those with dismissing/avoidant (insecure) attachment states of mind also have lower levels of mentalization as measured by the Reective Functioning Scale (Fonagy, Target, Steele, & Steeele, 1998). This study is also important because it makes a clear empirical link between attachment and the relational context of recovery and affect regulation in early psychosis. Those participants with avoidant mental states are rated by their keyworkers as having greater difculties in engaging with services. This shows that avoidant affect regulatory strategies whilst serving adaptive functions for individuals themselves have a consequence of placing greater pressure on services to assertively engage with this potentially vulnerable group. The fourth piece, by Lysaker and colleagues (2011) offers an outline of a systematic approach to addressing decits in self-reection in the psychotherapy of persons with prolonged schizophrenia. In this paper, it is suggested that decits in self-reectivity in schizophrenia can be thought of as decits in the capacity for self-reection. In other words, persons with schizophrenia vary in their capability to perform increasingly complex acts of metacognition. With that said, it is argued that psychotherapy can be conceptualized as aiding in the recovery of metacognitive capacity by providing a place in which such capacities can be practiced and exercised in order of increasing complexity. With such exercise and practice, metacognitive capacities that have atrophied or been damaged may be reclaimed such that more complex metacognitive acts can be performed

Paul H. Lysaker et al.

with greater ease in regular life. Following the metaphor of physical therapy, practicing of these capacities may be difcult and painful, but incremental progress is to be expected given the plasticity of the human organism. Turning to the issue of metacognition and severe personal disorders, Dimaggio and colleagues (2011), in the fth piece, summarize a model for metacognitive interpersonal therapy. Specically, they detail step by step how such a psychotherapy might promote a progressive awareness of the patients ability to dene problems in mentalistic terms and to use this knowledge to develop new avenues for living an adapted social life. Concrete descriptions are given for deciding which interventions are to be offered when. These principals are illustrated with a case report of treatment of a woman with obsessive-compulsive and other personality disorders. Our sixth paper is provided by Vanheule, Verhaeghe, and Desmet (2011), who summarize the literature on the impact of alexithymia, or the inability to name ones own affects, upon psychotherapy. They offer a model of why classic psychotherapeutic approaches fail in an attempt to address this decit. They then offer a detailed formulation of the principles for an alterative psychotherapeutic intervention that addresses the theoretically discerned difculties. Case-materials are used to illustrate how these principles can be implemented in clinical practice. Finally, Fonagy, Bateman, and Bateman (2011) have brought together the conceptual and empirical research presented in this special issue. They provide a masterly discussion of the evolutionary and ontogenic origins of mentalizing; the assessment of mentalizing, mentalizing as a trans-diagnostic concept, and mentalizing as a therapeutic technique. It is our hope that these papers taken as a whole, instead of providing closure, will stimulate more work on that which is so often not noticed among persons with serious mental illness, that is, how those persons think and fail to think about thinking and in as much help us understand the roots of dysfunction and aid in the development of treatment.

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