MERIT Therapy for Schizophrenia and Serious Mental Illness

Last week, I attended a training on Metacognitive Reflection and Insight Therapy (MERIT).

MERIT is one of several metacognitive psychotherapies, designed especially to meet the needs of individuals living with serious mental illnesses, including schizophrenia. It is deliverable in both group and individual settings, and it aims to improve metacognitive capacities through specialized interventions.

Metacognitive Capacities and Psychosis

Metacognition is a word utilized in fields ranging from education to mental health, often with subtle differences in meaning. Broadly, it references how one thinks about the process of thinking, or one’s own cognition in particular. Therefore, the simplest definition of metacognition might be understanding how we and others think. It involves self-reflection, understanding others, considering greater trends, and using all this information to make meaning and move toward our valued goals.

Psychosis often involves alterations in the integration of information, perceptions, and sensations. It deeply affects how we decipher who we are, our aspirations, our relationships, and the world. A study comparing metacognition capacity in individuals diagnosed with schizophrenia and bipolar disorder found that those living with schizophrenia struggled more with specific aspects of metacognition than those with bipolar (Tas et al., 2014). Schizophrenia may have a distinct profile of impact on metacognition.

MERIT’s Approach

MERIT is a psychotherapy designed to support individuals with serious mental illness (Lysaker and Klion, 2017). Rather than just focusing on reducing symptoms or challenging unwanted thoughts, MERIT attempts to deeply engage with a client to make sense of their world (both internal and external) and what they wish to create in it.

MERIT involves eight core processes:

Attention to Agenda

Here, agenda means what a person is getting at beyond the words they are saying. Clients have an intention of what they desire from therapy and their recovery, which often changes from session to session. Similarly, the same sentence can be hinting several different things in different contexts. In MERIT, therapists pay close attention to this.

Therapist Transparency/Self-Disclosure

MERIT encourages clinicians to share their thoughts openly and to provide targeted self-disclosure. This is something I appreciated learning about in this approach, as therapists are as human as anyone in therapy, and I believe that relating as such is core to the healing that can take place in psychotherapy. It is an element that makes therapy with a person different from AI.

Narrative Analysis

The narratives we craft for ourselves are key to how we make sense of our lives and relationships. In MERIT, the therapist is interested in stories a client creates from day to day to figure out the past, present, and future. Understanding these stories is critical for the therapist to relate effectively to what the world might look like from behind the client’s eyes.

Problem Definition

My understanding of this element is that the therapist and client ought to be on the same page regarding the purpose of therapy. In MERIT, the therapist does not tell clients what is wrong, but the client takes the lead in sharing what they perceive as challenging.

Dyadic Reflection

Dyadic reflection is a fancy term for times when the therapist and client talk openly about the relationship and each other’s perspectives. The concept reminded me of mentalization-based therapy’s ‘mentalizing the relationship.’

Client Assessment

In this psychotherapy, the view of the client in terms of their progression towards their identified goals is central. Rather than taking an authoritarian stance, the practitioner reflects with the client on how therapy is met and its effectiveness. In the case of psychosis, this is noteworthy as there has been an unfortunate tradition of mental health professionals projecting their realities onto a client (for example, trying to convince a client to accept a diagnosis). I found the respect for the clients’ vantage points refreshing.

Specific Reflections and Stimulating Mastery

These last two core elements focus on building up the ability of metacognition/reflection through practice. The therapist utilizes interventions to catch the client’s current level of metacognition and to help them advance. With time, participants can apply their newfound insights and capacities outside therapy.

Hope, Research and Recovery

A few trials have explored MERIT’s impact on individuals living with schizophrenia. One randomized trial revealed that MERIT improved individuals diagnosed with schizophrenia’s ability to use reflection to cope with their challenges (Hasson‐Ohayon et al., 2024). Another study found that when delivered in a group format, MERIT improved recovery-oriented beliefs in participants with a schizophrenia diagnosis (Musket et al., 2024). While data is still early, and more research is needed, MERIT shows promise as a psychotherapy for schizophrenia.

I found the philosophy behind MERIT to be reverential to people with mental health conditions. The partnership between therapist and client seems to value perceptions beyond any kind of pathology. Though I am admittedly still new to its approach, I am appreciative that it exists.