Recovery, Meaning-Making, and Severe Mental Illness

A Comprehensive Guide to Metacognitive Reflection and Insight Therapy

Paul H. Lysaker, Reid E. Klion

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781315446981
• Edition: 1
• Topic: Psychologie
• Subtopic: Psychopathologie

Recovery, Meaning-Making, and Severe Mental Illness offers practitioners an integrative treatment model that will stimulate and harness their creativity, allowing for the formation of new ideas about wellness in the face of profound suffering. The model, Metacognitive Reflection and Insight Therapy (MERIT), complements current treatment modalities and can be used by practitioners from a broad range of theoretical backgrounds. By using metacognitive capacity as a guide to intervention, MERIT stretches and strengthens practitioners' capacity for reflection and allows them to better use their unique knowledge to help people who are confronting the suffering and chaos that often comes from psychosis. Clinicians will come away from this book with a variety of tools for helping clients manage their own recovery and confront the issues that accompany an illness-based identity.

Section II
MERIT’s Preconditions and Eight Core Elements

5
Preconditions for Implementing MERIT

MERIT provides an integrative framework for practitioners who work from a range of perspectives to direct the delivery of psychotherapy interventions that will lead to recovery by facilitating the growth of metacognitive capacity. We believe this methodology can assist therapists who work with persons with the full range of serious mental illnesses, both those who are experiencing very severe symptoms and those who are less impaired.

We assume that persons who are interested in learning to provide MERIT have already been trained in and are familiar with the fundamentals of providing psychotherapy. This includes understanding the relevant ethical and moral standards as well as the common factors of psychotherapy such as the need to establish a therapeutic alliance, maintain a non-judgmental stance, the importance of managing boundaries, and the criticality of being respectful of patients at all times.

While MERIT is not a rigid, prescriptive treatment methodology, the beliefs of therapists who implement it matter greatly. What a therapist expects can and should happen in treatment will influence how he attends to what patients say and what is understood. As such, this chapter will detail several specific ways of understanding serious mental illness that make the practice of MERIT possible. We refer to these as MERIT’s preconditions. Each of these beliefs, or preconditions, bears upon how recovery is understood and the role both the patient and the therapist play in the process. It is critical that the therapist be comfortable with these principles because they provide the foundation for MERIT’s recovery-oriented approach.

Precondition I: Recovery From Severe Mental Illness Is Possible

The first concept with which the MERIT therapist has to be comfortable is that people with serious mental illness can and do recover. This seemingly reasonable and non-controversial statement is well-supported by empirical research as well as first person reports (Davidson, 2003; Harding et al., 1987; Leonhardt et al., in press). However, while broadly accepted in the abstract, seeing recovery as a likely outcome for a specific individual being seen in treatment in the midst of an acute exacerbation or crisis is often more elusive. Sitting alone in a consulting office hour after hour with patients with serious mental illness can be disorganizing or even frightening for some therapists. Trying to understand the experience of someone who is in the midst of acute psychosis, paralyzed by pervasive hopelessness, or in a highly dysregulated state can be bewildering and intimidating. It is difficult to form ideas in one’s own mind about the other when that other is actively experiencing the world as a chaotic and terrifying flow of unrelated fragments. This challenge is often compounded by both the tendency to attribute the behavior of others to enduring traits rather than situational factors and an often pervasive sense of pessimism about the course of mental illness. The result is that clinicians are often tempted to believe that the specific person before them can at best resolve her acute problems and achieve “stability” but is unable to actually recover and substantially improve the quality of her life. This is often reinforced by institutions where the explicit goal is to stabilize and transfer patients as quickly as possible to a lower level of care; unfortunately, the concept of long-term growth and improvement is not even considered because it is simply not part of the organization’s thinking or mission.

Given both these pressures in the moment and the larger institutional zeitgeist, it is easy to see how clinicians can routinely lose sight that recovery can be an achievable and realistic goal. Additionally, patients themselves, who have often come to see themselves as helpless or perhaps even find some level of comfort or acceptance in a sick role, can encourage therapists, either implicitly or explicitly, to not see the potential for recovery in them. However, to consider recovery precludes the possibility of effectively delivering MERIT because it does not view stability or absence of acute distress as meaningful goals for treatment.

To accept that a unique person can recover requires complex metacognitive activity on the therapist’s part. Seeing someone in a state of distress or profound disengagement from the world requires the formation of a complex idea about that person. The patient must be recognized as an individual who can experience widely different states over the course of her life which may include a successful premorbid period, grave current impairments, and the ability to have a satisfactory and rewarding life in the future. In this, wellness must be understood as more than the resolution of an acute problem and as participation in the world in a way that is not only free of disabling pain but is personally meaningful.

Maintaining the belief that recovery is real and likely for all patients is far from simple because the dynamics that promote recovery are poorly understood. Persons can emerge from unfathomable levels of psychosis in ways that are not always anticipated. How and why symptoms will remit is not well understood, and the long-standing belief that wellness results from simply following orders and taking medication is not empirically supported (Harrow et al., 2014). While on the one hand MERIT therapists must accept the stance that recovery is possible, the path to it for each individual is uncertain and cannot be known ahead of time.

MERIT Precondition II: Patients Are Active Agents in Their Recovery

The second precondition is the belief that patients must be seen as active agents in their own recovery, both in terms of setting goals for treatment and determining how to achieve them. Here, MERIT embodies the concept of self-directed recovery (Davidson, 2005; SAMSA, 2005). As with the prior precondition that recovery is possible, therapists will often be familiar with the literature supporting the role of patients as active agents in their recovery (Davidson, 2003; Roe, 2001, 2005) and accept it in principle. However, therapists are often understandably made anxious when patients with serious mental illness are in the midst of acute psychosis, pervasively demoralized, or in a highly dysregulated state, provoking the clinician to take charge of the specific person in this specific circumstance.

Indeed, crises will inevitably emerge in work with severely impaired persons where firm action is needed such as when there is an acute risk for self-harm. However, what needs to be avoided is the insidious process by which therapists lose or fail to establish the idea that the specific person they are treating eventually will be able to seek and direct his own recovery. This dynamic is also reinforced by institutional concerns about risk management and patient safety which may lead clinicians to become preoccupied with any number of fantasized negative outcomes if they do not take control in a given situation. Additionally, as is the case where patients are not sure they can recover, patients and those around them may have also come to accept that they should not try to determine their own paths to recovery and that attempting to do so may lead to disaster.

MERIT is not a treatment that conceptualizes health as simply attaining “stability” or “diminishing short-term distress” as meaningful goals. Just as is the case with seeing recovery as a realistic outcome, accepting that a person can direct her own recovery also requires a complex metacognitive act on the part of the therapist. While therapists need to see the patient as a person with genuine struggles and some very real limitations that cannot be minimized, the patient also needs to be seen as capable of making sense of the psychiatric challenges she has faced and ultimately find a way to make life better for herself. For example, without losing sight of readily apparent neurocognitive deficits, symptoms, trauma history, previous self-destructive behaviors, poor choices, and interpersonal hostility, the therapist has to understand that patients can reflect upon their own experiences and determine what is personally meaningful to them and how they might choose to lead their lives.

In sum, therapists must form an ongoing and evolving multifaceted understanding of their patients. The presence of real limitations and the potential to understand and direct one’s own life must be integrated within the therapist’s understanding of patients. In the case of both the first and second preconditions, MERIT is not asking for therapists to stop being reflective and naively accept without question simple black or white assertions. The goal here is not to establish a “Pollyanna” view of profound disturbances in the lives of others. Indeed, not all patients will get better, and there is no reason to believe that MERIT will necessarily be able to help everyone. However, what each of these preconditions calls for is the belief that even the most confused patient can eventually be understood and can overcome profound barriers, ultimately finding ways to have a healthier life which is enriching for himself and others.

MERIT Precondition III: The Therapist’s Role as Consultant and Equal Participant

The third basic understanding, closely tied to the first two, is that the patient-therapist relationship must be non-hierarchical. This is based upon the foundational belief that meaning-making is something constructed between two co-equals, not the result of a more powerful person directing or teaching someone who has less power.

Again, this is not always easy to achieve. Many patients have been socialized by the culture of mental health systems and the messages embedded in our larger social discourses that portray clinicians as more powerful and knowing than they are. Additionally, problems are often understood by patients and their families to result from “not listening to the doctor.” Here, it is not uncommon to encounter a patient who relates a story in which she ignored medical advice, stopped taking a prescribed medication, experienced something undesirable, and then decided her judgment could no longer be trusted. As a result, people with such experiences often come to treatment with the expectation that they are going to be told how to recover.

Additionally, clinicians are in a more powerful position than patients in several ways, and this inevitably creates an unequal relationship. Clinicians often do possess professional expertise and the experience of having known many others who have struggled with serious mental illness. The therapist is paid, with sessions generally taking place in her office, and, if sufficiently alarmed, can take steps that will lead patients to being hospitalized against their will.

The result is that the power differential between the therapist and patient is real, and patients will often question their own judgment because of it. The key for the therapist is to assume the role of a consultant in the interaction with patients. Therapist reflections are offered as something for the patient to consider that may be accepted, rejected, or set aside because it is ultimately the patient’s responsibility to decide how to respond to and use them. Similarly, it is expected that there will be negotiation, especially at the start of therapy, about what is to be discussed in treatment as well the therapist’s role and boundaries of the relationship. Agreement on these points must be worked toward, not assumed a priori (Hasson-Ohayon & Lysaker, 2017).

MERIT also encourages therapists to consult with patients about the meaning they are making and not to attempt to “supply” it to them. Trying to provide solutions which patients can simply choose or reject is to be avoided as well as should trying to help the patient accept the “wiser” therapist’s conceptualization of the problem. Consistent with other work on recovery, meaning-making occurs in the space between two persons and requires dialogue on an equal plane (Buck et al., 2015). As a result, this requires great sensitivity when offering thoughts so that they do not coopt the meaning-making process. For example, if a patient were to report how ignoring a particular piece of advice led to a recent hospitalization, the therapist would not step in to offer a “truth” such as suggesting it is best to not ignore such advice in the future; instead the dyad might attempt to jointly understand the events and feelings leading up to the hospitalization. The process of sharing therapist reflections in a w...