Metacognitive Insight and Reflection Therapy (MERIT)

MERIT is a recovery-oriented form of integrative individual psychotherapy designed to help persons diagnosed with psychosis form more integrated ideas of themselves, others, and the psychiatric and social challenges they face (^{Lysaker & Klion, 2017}; ^{Lysaker et al., 2020}). In MERIT, the construct of metacognition is used to describe the processes which allow persons to integrate information and form the kinds of complex storied sense of self and others needed to make sense of what is emerging within the flow of life and then decide how to respond (^{Semerari et al., 2003}). Metacognition is further understood as a primarily intersubjective phenomenon in which all human beings fundamentally make meaning with others and not in isolation (^{Hasson-Ohayon et al., 2017}, ²⁰²⁰).

MERIT's goals are to promote metacognitive capacity. As metacognitive capacity increases, persons are believed to be better able to integrate information and move from states in which the self and world are experienced as fragments with only loose connections to one another to states in which persons have more coherent and complex senses of the self and world which takes into account personal history and complex social relationships (^{Lysaker et al., 2011}). This movement towards integration is suggested to allow persons to make fuller sense of what has happened in their lives, including challenges related to psychiatric issues (e.g., symptoms, stigma, trauma), to decide how to manage and live with any resultant emotional pain, and ultimately direct their own path to recovery. Evidence supporting MERIT includes an array of randomized controlled trials, qualitative studies, and case reports (cf. ^{Lysaker et al., 2020}). For the clinical work under consideration here, all authors are trained MERIT therapists. All had extensive experience working with adult and/or adolescent patients with psychosis in outpatient settings in the Midwest or Northeastern United States for at least three years before the onset of the pandemic.

Metacognition, Meaning, and Reflection in Psychotherapy for Psychosis during the Time of COVID-19

There are many longstanding assertions that human beings have a hierarchy of needs and in times where basic needs are endangered, higher needs quickly lose their relevance (^{Maslow, 1954}). With this in mind, it could be possible that the processes of exploring meaning in life and trying to understand a personal history of mental health challenges in MERIT might cease during COVID-19. Perhaps worries about personal safety might cancel out any wish by patients to form a larger understanding of one's life. Each of us privately worried it might.

Nevertheless, in the past month each of us has observed the reflective processes that were occurring among patients previously engaged in MERIT persisted after the spread of COVID-19 in the United States. Following awareness of the dire risks that come with the pandemic and a change to a video or telephone session, none of us observed the processes of thinking about life and its meanings were diminished in our ongoing contacts with patients. Consistent with observations made by ^{Frankl (1992)}, the need to continue to make larger meanings of one's experience of oneself in the world were as pressing as ever. Patients who had been attending regular sessions chose to continue attending and thinking about their own thinking and how they understood their place in the world. Perhaps, during a time when social structures and basic safety are challenged, like that of COVID-19, there was an even greater need to sustain and find purpose in the connection that emerged between patient and therapist and to not sink back into a state in which self and the world again became less coherent and more fragmented. For most patients, reflections about who they are and have been as persons in the world continued to deepen, sometimes in ways that were surprisingly in response to the pandemic challenges. Indeed, as we will now detail, COVID-19 seemed to offer novel ways to engage in this work.

The Changing Contents and Relationship to Recovery from Psychosis in MERIT following the Emergence of COVID-19

If the answer to the question "can MERIT continue during the COVID-19 pandemic?" is tentatively affirmative, the next question to be addressed is how and in what ways the content of this therapy has changed. Certainly, the contents of that therapy must have changed and, if so, the next question is "in what ways?". Of note, MERIT does not contain a curriculum but instead consists of a set of elements which emphasize joint meaning making. Naturally, reflections about COVID-19 and its impact thus emerged for most patients relatively quickly. These reflections colored each patient's account of their thoughts, emotions, and wishes in their lives though in different ways. For example, some noted all of these changes during this period of the COVID-19 pandemic had left them feeling resigned and waiting for life to return to what it had been before. Some patients noted that part of their resignation was an acceptance that they were feeling trapped again and as if things they had previously gained would be lost. Following the dictates of MERIT, this allowed for fertile discussion of that experience.

For other patients, COVID-19 did not engender defeat but produced some remarkable changes in the kinds of reflections about the self and others that dominated each session. The most prominent of these reflections is that with COVID-19 many patients experienced and thought about their place and position in the social world in a way that was distinctly different than it had been before the pandemic. Commonly, the patients had previously felt cut off from others, had a perceived low social rank, and believed they possessed few social resources. With COVID-19, some patients' senses of loneliness changed. Their sense of isolation had suddenly with COVID-19 become something that was similar to and not qualitatively different from what many other felt around them. For example, adolescents who were in one-on-one classrooms in school suddenly found that the classes they felt ostracized from were dissolved and all their peers were now also roughly cut off from each other, and that this mirrored what they had felt prior to COVID-19. Other adult patients who generally felt like they had little to offer others now noticed they possessed survival skills (e.g., veterans with deployment experience) which seemed to result in a revived sense of oneself as more capable. One patient, who routinely lived in a state of panic and fear which made him an outcast, was now existing in a world in which many around him shared that view. Patients who are working have felt a greater sense of purpose and a new feeling of being an essential part of their community. All of this stimulated reflections in which patients' internal experiences were understood as existing on a shared continuum of human experiences and with that came a reduced sense of profound otherness with regards to other people. Emotional pain could be more easily expressed without a fear in the background that pain was something abnormal or a kind of pathology. As such, some patients normalized experiences they had previous seen as deviant in ways they had not before and there were opportunities for growth in self-reflectivity.

Patients' reflections about others and their place in the larger community (referred to in MERIT as decentration), also seemed to change in a number of related ways. Some patients now experienced others as more vulnerable and with more apparent needs than had been previously realized. There were more comments in which patients seemed to share and be interested in the perspectives of others. They could talk about experiences others were now having that they had long experienced in their own lives, like frustration, boredom, and fears for safety. For some, a curiosity about others' mind emerged that therapists had not noticed previously. The behavior of others, including the therapist as well as family and friends, became interesting and discernable, leading to the potential for some patients to form richer ideas of their connections to the larger social world. Nearly every patient was noted to ask more about the therapists' well-being and to seem to form a somewhat more complex idea of who the therapist was as a person. Each of us indeed had the experience of being asked more about ourselves, as well as having the opportunity to use self-disclosure in healthy ways, which would have previously been perceived as threatening, that may have further scaffolded patients' self-reflection within the session.

Finally, COVID-19 also offered therapists new ways to think about patients and the issues that were emerging in MERIT. For example, many of us found an opportunity to see in the world of COVID-19 a broader sense of fragmentation and disconnection which mirrored what our patients had been experiencing for years. Although it has been quite difficult to confront our own experiences of fragmentation brought on by this pandemic, we found that as we sat in confusion with our patients it was as if our own vulnerability offered a platform for patients to reflect more meaningfully on their previous and continuing confrontations with confusion.

Inequality and lack of social justice were also made apparent as it was clear that many patients were at heightened risk to become ill and potentially die. This challenged us to think about the complexities inherent in our relationships with and role in our patients' lives and their communities. Therapists found themselves worrying about safety and well-being in the face of this pandemic and continually explored ways in which these concerns can be incorporated into the work. One common dilemma that has emerged since COVID-19 concerns how to be concretely responsive to emergent needs while also promoting reflection without losing an open interpersonal stance that does not condescend or infantilize patients (^{Hamm et al., 2016}).

The Changing Platform of MERIT, the COVID-19 Pandemic, and Intersubjectivity

Just as MERIT changed with the introjection of everyone's experience of the world's response to COVID-19, MERIT also changed with the rapid and unanticipated shift from face-to-face meetings to video and/or telephonic sessions. Perhaps most prominently, access to many of the subtle things that happen between two people when they are sitting in an office together was lost. Qualities of the intersubjective exchange itself were thus changed.

These changes also resulted in a number of unexpected opportunities as the work of MERIT continued to move forward. One of the more surprising things therapists saw across cases was the opportunity to talk more deeply about the therapeutic relationship. For one patient, the physical distance spurred new thought and awareness of the attachment he had formed with the therapist and more significantly his pain associated with separateness and potential loss. This reflection allowed for an even deeper set of reflections about how he related not only to the therapist but to others across his life.

The issue of the therapist's location also seemed to have effects which spurred further reflection, in particular the thought that therapists might be performing clinical services from their homes. One patient noted that he did not want to talk to his therapist if she started to work from home because he did not want to know too many things about her, and in particular, how that might threaten his image of her as fragile and unidimensional. Upon more reflection, he flatly said he did not want to talk to his therapist from home since across much of his life he had "never known how to act in other people's homes," and closeness to others always led to rejection and destruction. Again, following the dictates of MERIT this led to fertile and compelling discussion of the patient's experience and what they wanted from life but also his lifelong tendency to find distance from others safer than closeness. Simply put, even in states of significant distress, patients in MERIT continued to try to reflect upon themselves and others and to assemble or integrate previously fragmented experiences, allowing them to respond to the world from the position of an agent and one connected to others and their community.

Other patients seemed to thrive when there was just video or telephonic contact regardless of the therapist's location. For one patient, it seemed that without the stimulus value of the therapist's physical presence he could think more clearly about himself and be less concerned about how she was judging or seeing him. For another patient with an erotic transference, his preoccupation with his therapist lessened over the telephone and he could disclose to the therapist and to himself more meaningful reflections about how his life had unfolded. Still another patient noted being surprised by how the phone made him have to willfully wonder what was in the therapist's mind and what her expression might be at the moment, now that that information was not readily available to him. To scaffold this metacognitive activity, the therapist used interventions to stimulate reflection of previous sessions in which he remembered the expression that he presently imagined. He and many others reflected their surprise that a sense of connection persisted and did not vanish despite the physical distance, providing a foundation for reflections about themselves, their relationships to others, mental health challenges, and what was possible for them in life.

It has been suggested that intersubjectivity for many with psychosis may feel threatening for two reasons: the other can see and judge them in ways that may be difficult to ward off and the other may elicit feelings which are difficult to integrate or manage (^{Lysaker & Lysaker, 2008}). It is possible that virtual sessions might lessen these threats and allow for unique content to emerge. As an illustration, in one virtual session, a patient who had been receiving MERIT for over a year reflected for the first time that his preoccupation with anger and often homicidal stances towards others was futile. He was also able to acknowledge briefly how these practices had protected him from feeling badly about himself and consequently they were difficult to abandon. We speculate that in this case being in a virtual space made it safe to make these observations for several reasons. First, the patient's sense that he could not acknowledge weakness to a woman may have been lessened by their not being physically present in the same office. There may also have been a decreased threat of potential judgment via facial expressions. It also seemed like he might have been more willing to take a risk and be vulnerable if there was an immediate escape possible from the session (i.e., ending the session by hitting a button). For another patient, telephone sessions also seemed to make it easier to talk since he was freed of what had been observed previously to be social anxiety about how he appeared to others. Given there is no context of an office space, it seemed that distant technologies have had an equalizing effect and may have helped to further allow for the therapeutic relationship to be nonhierarchial.

For both therapists and patients, other differences were noted as well. Without the cues that come from physical presence, therapists also had to focus more carefully on exactly what the patient was saying. Silence also seemed to take on new qualities. For some patients, silence revealed their persistent insecurity and provided a chance to talk about how difficult it was to know the therapist both in a virtual setting but also even in the past when in person. For others, silence seemed easier as there were no awkward expressions exchanged. With silence being uncertain and missing some of the cues that come from being in person, therapists found themselves focusing very carefully on the words of the patient and perhaps less likely in many cases to interrupt, allowing for things to emerge in the course of the session which felt novel and productive.

Summary and Conclusions

MERIT is a form of individual psychotherapy that seeks to synergistically stimulate patient's abilities to think about themselves and others and to use this reflective knowledge to respond to, manage, and live with diverse challenges that often accompany psychosis. Concretely, this therapy helps patients form increasingly integrated ideas of themselves and others, their fragmented experiences giving way to coherence. With these patients each therapist had been providing this kind of treatment for periods of months to years when the pandemic hit the United States and new challenges and a new platform for therapy were suddenly introduced.

In this paper we have reflected upon our experience in the weeks since and at this point can only conclude that this form of therapy has remained viable and effective. Following older ideas of ^{Frankl (1992)} it seems with greater suffering and challenges comes an even greater need for meaning making and connection with others. In terms of what modifications were needed, there are several answers to be gleaned from our reflections. First, discussions ensued in which patients naturally discussed what the COVID-19 pandemic meant to them. In parallel to how previous discussion generally focused on meaning, so did these conversations. Thus, the spirit of the therapy was unchanged as new material was introduced. Second, MERIT remained focused on helping patients sort out and decide what kinds of thoughts the COVID-19 pandemic spurred on in them about their lives and history as well as that of others. As it had in the past, thoughts and ideas were produced that could be used to form a richer sense of patients' lives in the moment. Third, challenges and changes in the relationship were available as material for reflection, also in line with the spirit of the treatment. In summary, at the risk of oversimplification, nothing yet about the spirit of MERIT has changed regarding "how" patients reflected upon their experience because as a treatment MERIT was responsive to the profound changes in "what" patients were experiencing.

Importantly, these are preliminary observations and there is need for far more systematic study as the effects of COVID-19 continue to unfold. We hope that the ideas here will serve as a starting point and future guide for this work. None of us support moving away permanently from face-to-face contact in psychotherapies concerned with meaning. Notably, the vast majority of the patients discussed here had been engaged in MERIT for months, if not years. We doubt that deep bonds can be as easily built with persons experiencing profound fragmentation without opportunities for those patients and therapists to sit in the same room and try to relate to one another. Nevertheless, there is much to be learned from exploring what happens during this time to therapies such as MERIT concerned with meaning and subjectivity. Many questions remain unearthed by the pandemic. We assume that intersubjectivity is compromised by a lack of face-to-face contact, but the question remains as to how exactly this intersubjectivity is altered. What small, but important, pieces of information are lost and how do those affect the metacognitive processes of the therapist and more broadly the dyad? Do times of crises force patients and therapists to see the larger world and its real frailty, and how does that affect metacognition?