Papers by Ilanit Hasson-Ohayon
Authorea (Authorea), May 17, 2023
Homework assignments in psychoanalysis are contentious; some believe they contradict psychoanalyt... more Homework assignments in psychoanalysis are contentious; some believe they contradict psychoanalytic principles, while others argue they enhance coping skills. We propose that homework can be a legitimate aspect of relational psychoanalysis when used in a way that is attuned to the patient’s experience and that homework may be an important component of treating personality disorders. We present the case of a man diagnosed with narcissistic personality disorder to illustrate this: the patient, wrestling with social relations and control dynamics within therapy, was assigned homework aimed at curbing his compulsive caregiving and exploring its underlying motives. This exercise led him to understand his actions stemmed from avoidance of exposing his vulnerabilities. Subsequently, he was able to engage with relationships from diverse perspectives and discover new meanings. We advocate that homework tasks can be successfully incorporated into the relational psychoanalytic approach, fostering self-reflection and facilitating transformative change in patients with personality disorders.
Psychology Research and Behavior Management, Apr 1, 2020
Recent research has suggested that recovery from psychosis is a complex process that involves rec... more Recent research has suggested that recovery from psychosis is a complex process that involves recapturing a coherent sense of self and personal agency. This poses important challenges to existing treatment models. While current evidence-based practices are designed to ameliorate symptoms and skill deficits, they are less able to address issues of subjectivity and self-experience. In this paper, we present Metacognitive Insight and Reflection Therapy (MERIT), a treatment approach that is explicitly concerned with self-experience in psychosis. This approach uses the term metacognition to describe those cognitive processes that underpin self-experience and posits that addressing metacognitive deficits will aid persons diagnosed with psychosis in making sense of the challenges they face and deciding how to effectively manage them. This review will first explore the conceptualization of psychosis as the interruption of a life and how persons experience themselves, and then discuss in more depth the construct of metacognition. We will next examine the background, practices and evidence supporting MERIT. This will be followed by a discussion of how MERIT overlaps with other emerging treatments as well as how it differs. MERIT's capacity to engage patients who reject the idea that they have mental illness as well as cope with entrenched illness identities is highlighted. Finally, limitations and directions for future research are discussed.
Psychiatric Rehabilitation Journal, Dec 1, 2020
OBJECTIVE It has been established that recovery is a common outcome for adults diagnosed with ser... more OBJECTIVE It has been established that recovery is a common outcome for adults diagnosed with serious mental illness which involves objective and subjective phenomenon. While considerable work has examined objective aspects of recovery, it remains difficult to know how to quantify the processes which support more subjective aspects of recovery related to sense of self. This article explores the potential of recent research on metacognition to offer new avenues to measure the processes which make a sense of self available within the flow of life. METHOD Emerging definitions of metacognition using an integrative model of metacognition are reviewed. Research is presented suggesting adults diagnosed with serious mental illness are often confronted by metacognitive deficits which interfere with their ability to make sense of their psychiatric challenges and effectively direct their own recovery. FINDINGS Metacognitive capacity may be a quantifiable phenomenon which contributes to certain aspects of recovery related to meaning making, agency and self-direction. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE Promoting metacognitive capacity may be a previously unrecognized active element of existing rehabilitative interventions. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
World Psychiatry, Sep 9, 2021
359 and tocilizumab and, equally importantly, the lack of benefits of hydroxychloroquine, lopinav... more 359 and tocilizumab and, equally importantly, the lack of benefits of hydroxychloroquine, lopinavir-ritonavir and azithromycin in patients hospitalized with COVID-19. The speed and power of the results obtained from a trial of extreme simplicity, with a singleminded dedication to maximizing recruitment across a health system, are impressive. By radical simplification of procedures to minimize patient and clinician burden, RECOVERY has provided an example of a sustainable rolling trial platform which allows the sequential evaluation of multiple agents. The simplicity and speed of RECOVERY did not come at the cost of sacrificing quality or the short-cutting of ethical or regulatory oversight. Instead, the RECOVERY investigators worked closely with both the ethics committees and the UK regulator in parallel with setting up the trial, achieving a hitherto unimagined speed of trial set-up. I believe that we urgently need to apply the lessons learned from RECOVERY in mental health trials. We have previously identified the potential for large, streamlined trials in mental health, although this approach remains unusual. One exception is the BALANCE trial comparing long-term treatments in bipolar disorder. In this trial, we did radically simplify procedures and achieved a reasonably sized sample with a clear primary outcome. Building on the example of RECOVERY, we now need to scale up trials such as BALANCE by an order of magnitude to allow multiple arms and deliver strong evidence of modest (but worthwhile) treatment effects. There is no shortage of important clinical questions that need answering via large-scale, streamlined, directly randomized studies. As with RECOVERY, we should initially focus on comparative efficacy of existing, licensed interventions, adding more innovative treatments once the platform is up-and-running. A prime illustrative example is the comparative efficacy of antidepressant drugs. A network meta-analysis reported that there are potentially clinically important differences between 21 available antidepressants, but that nearly all the comparative data are indirect and based on pre-regulatory approval trials. This is a major gap in the evidence base and a substantial barrier to knowing which antidepressant might be most likely to be effective for any specific patient – the goal of precision psychiatry. Large-scale, streamlined trials should be designed in partnership with a broad range of stakeholders, including patients, regulators and industry, and recruiting a broad range of patients from routine clinical settings. Large-scale recruitment can be facilitated by using electronic health records. Progressing this idea using the momentum and learning from RECOVERY seems to be an outstanding opportunity for mental health clinicians, researchers and patients, and needs to be supported by funders. Finally, the COVID pandemic helps to clarify the relative strengths of randomized and observational studies. Early on, considerable publicity was given to small, uncontrolled reports of the potential benefits of hydroxychloroquine. A report of routinely collected observational data seemed to confirm this, only to be quickly retracted. RECOVERY found no benefit of hydroxycholoquine in severely ill patients, although there remains the possibility that it might be effective in very early or mild cases. This demonstrates the danger of retrospective analyses of data of uncertain provenance as well as the power of large simple randomized controlled trials. On the other hand, observational data of infection rates following vaccinations were hugely reassuring, given the remaining uncertainties around vaccine efficacy in specific patient subgroups. Observational data can extend and confirm the results of randomized trials, which will always remain smaller and less representative. These data are increasingly available via electronic care records and, although susceptible to residual confounding even after multivariate propensity score matching, may be very valuable for post-marketing safety surveillance and confirmation of treatment effects in larger, more representative datasets. In conclusion, despite the human tragedy and suffering, the COVID-19 pandemic has inspired some outstandingly creative responses from the international research community. We need to capture this and apply it to the major global challenge of mental illness, building on the developing international collaborative efforts. We should draw inspiration from just how much can be achieved so quickly with a clearly defined objective and common sense of purpose and urgency.
DOAJ (DOAJ: Directory of Open Access Journals), Apr 1, 2020
Recent research has suggested that recovery from psychosis is a complex process that involves rec... more Recent research has suggested that recovery from psychosis is a complex process that involves recapturing a coherent sense of self and personal agency. This poses important challenges to existing treatment models. While current evidence-based practices are designed to ameliorate symptoms and skill deficits, they are less able to address issues of subjectivity and self-experience. In this paper, we present Metacognitive Insight and Reflection Therapy (MERIT), a treatment approach that is explicitly concerned with self-experience in psychosis. This approach uses the term metacognition to describe those cognitive processes that underpin self-experience and posits that addressing metacognitive deficits will aid persons diagnosed with psychosis in making sense of the challenges they face and deciding how to effectively manage them. This review will first explore the conceptualization of psychosis as the interruption of a life and how persons experience themselves, and then discuss in more depth the construct of metacognition. We will next examine the background, practices and evidence supporting MERIT. This will be followed by a discussion of how MERIT overlaps with other emerging treatments as well as how it differs. MERIT's capacity to engage patients who reject the idea that they have mental illness as well as cope with entrenched illness identities is highlighted. Finally, limitations and directions for future research are discussed.
Frontiers in Psychiatry, Nov 11, 2021
Introduction: Social functioning is often impaired in the ultra-high-risk (UHR) phase of psychosi... more Introduction: Social functioning is often impaired in the ultra-high-risk (UHR) phase of psychosis. There is some evidence that empathy is also impaired in this phase and that these impairments may underlie difficulties in social functioning. The main aim of this study was to investigate whether cognitive and affective empathy are lower in people in the UHR phase of psychosis in comparison to healthy controls, and whether possible impairments have the same magnitude as in people with schizophrenia. A second aim was to examine whether there is a relationship between empathy and social functioning in individuals in the UHR phase. Method: Forty-three individuals at UHR for psychosis, 92 people with a schizophrenia spectrum disorder, and 49 persons without a psychiatric disorder completed the Interpersonal Reactivity Index (IRI), Questionnaire of Cognitive and Affective Empathy (QCAE), and Faux Pas as instruments to measure empathy. The Time Use survey was used to measure social functioning. MAN(C)OVA was used to analyse differences between groups on empathy and social functioning, and correlations were calculated between empathy measures and social functioning for each group. Results: The UHR group presented significantly lower levels of self-reported cognitive empathy than the healthy controls, but not compared to patients with SSD, while performance-based cognitive empathy was unimpaired in the UHR group. On the affective measures, we found that people with UHR and patients with SSD had significantly higher levels of self-reported distress in interpersonal settings compared to healthy controls. In the UHR group, perspective-taking was negatively associated with time spent on structured social activities. In the SSD group, we found that structured social activities were positively associated with perspective-taking and negatively associated with personal distress in interactions with others. Lastly, in people without mental illness, social activities were positively associated with performance-based perspective-taking. Kuis et al. Empathy Social Functioning UHR Psychosis Conclusion: Impairments in subjective cognitive empathy appear to be present in the UHR phase, suggesting that difficulties in interpreting the thoughts and feelings of others precede the onset of psychotic disorders. This can inform future interventions in the UHR phase.
Journal of Clinical Psychology, Jul 7, 2021
One recent development within the realm of psychotherapeutic interventions for schizophrenia has ... more One recent development within the realm of psychotherapeutic interventions for schizophrenia has been a shift in focus from symptom management to consideration of metacognition, or the processes by which people synthesize information about themselves and others in an integrated manner. One such approach, metacognitive reflection and insight therapy (MERIT); in particular, offers a description of 8 therapeutic activities that should occur in each session, resulting in the stimulation and growth of metacognitive capacity. In this report, we present a description of 12 sessions with a patient suffering from schizophrenia manifesting significantly disorganized symptoms. Each MERIT element is described along with observed clinical and metacognitive gains. As illustrated in this report, these procedures helped the patient move from a state of having no complex ideas about himself or others, to one in which he could begin to develop integrated and realistic ideas about himself and others and use that capacity to think about life challenges.
Elsevier eBooks, 2014
Across the history of psychotherapy for schizophrenia, multiple approaches have been proposed tha... more Across the history of psychotherapy for schizophrenia, multiple approaches have been proposed that might assist people with this condition to recover. In light of emerging literature on the how deficits in metacognition may represent profound barriers to recovery, this chapter will explore an integrative model of psychotherapy centered around the possibility that a key to facilitating recovery may involve assisting patients to recapture metacognitive capacity. Specifically, we explore eight overarching elements from a range of different theoretical perspectives and discuss how they may guide psychotherapy to assist patients to develop more complex representations of themselves and others. A method for assessing adherence to these elements is offered.
Psychiatric Services, Apr 1, 2021
Shared decision making (SDM) is an interpersonal health communication model that is underutilized... more Shared decision making (SDM) is an interpersonal health communication model that is underutilized with people with serious mental illness. Although research has emphasized the role of patient capacity-, clinician-, and system-related barriers in SDM underutilization, the risk taking that affects SDM with people with mental illness is less often discussed. This Open Forum presents a reconceptualization of SDM as a process of shared risk taking that often occurs during different phases of illness management and recovery. The concepts of intersubjectivity, meaning making, and metacognition are offered to inform clinical interventions needed to address risk in SDM.
Schizophrenia Bulletin, Oct 15, 2018
The integrated model of insight in schizophrenia suggests that poor insight is the result of mult... more The integrated model of insight in schizophrenia suggests that poor insight is the result of multiple factors which compromise persons' abilities to integrate streams of information into a personal awareness of psychiatric challenges, and make adaptive responses. This model hypothesizes that metacognitive deficits, or difficulties forming a complex and integrated understanding of the self and others, influence insight, regardless of other proximal causes including clinical profile. To explore this possibility, we performed a latent class analysis on 324 adults with schizophrenia or schizoaffective disorder. This analysis produced 4 groups on the basis of assessment of insight and Positive and Negative Syndrome Scale (PANSS) positive, negative, cognitive, and hostility symptoms. The resultant groups were characterized as: Good Insight/Low Symptoms (n = 71), Impaired Insight/High Negative Symptoms, (n = 43), Impaired Insight/High Positive Symptoms (n = 50) and Impaired Insight/Diffuse Symptoms (n = 160). When we compared metacognitive function as assessed with the Metacognition Assessment Scale-Abbreviated (MAS-A) across groups, we found that the good insight group had better overall metacognition as well as higher levels of self-reflectivity, awareness of the other and mastery as compared to all 3 groups with impaired insight. When controlling for total symptoms, all differences in metacognitive function between the good insight and the impaired insight groups remained significant. These results are consistent with the view that, independent of symptoms, impaired metacognition contributes to difficulties integrating information and hence impedes insight, or awareness of psychiatric challenges. Consistent with extant literature, results suggest that interventions focusing on metacognition as the target may lead to improved insight.
Schizophrenia Research, Dec 1, 2018
Schizophrenia involves a range of interrelated impairments in functioning due to symptoms and def... more Schizophrenia involves a range of interrelated impairments in functioning due to symptoms and deficits in varying domains of cognition including neurocognition, social cognition and metacognition. Yet little is known whether certain symptoms or cognitive impairments play a more central role than others. To explore, we conducted a network analysis of five types of symptoms, six domains of neurocognition and multiple aspects of both social cognition and metacognition. Participants were 81 adults with a schizophrenia spectrum disorder in a non-acute phase of the disorder. Results of the network analysis suggest that the cognitive symptoms node is most central in the network, metacognition abilities have high strength centrality measures followed by visual learning and emotion identification. In addition, distinction between the four groups of variables was supported. This suggests the need for both cognitive remediation and metacognitively oriented therapies in order to promote recovery from schizophrenia.
European Psychiatry, Oct 1, 2017
Background: Deficits in metacognition are one of the major causes of the difficulties experienced... more Background: Deficits in metacognition are one of the major causes of the difficulties experienced by individuals with schizophrenia. Studies have linked these deficits to symptom exacerbation and deterioration in psychosocial functioning. The aim of the present meta-analysis was to examine the extensive existing literature regarding metacognitive deficits among persons with schizophrenia; a further aim was to assess the extent to which metacognitive abilities are linked to outcome measures of symptoms and psychosocial functioning. Method: We conducted a systematic literature search of studies examining the relationship between metacognitive abilities and outcome measures among people with schizophrenia. We then analyzed the data using a random-effects meta-analytic model with Cohen's d standardized mean effect size. Results: Heterogeneity analyses (k = 32, Cohen's d = À.12, 95% CI.À1.92 to 1.7) produced a significant Q-statistic (Q = 456.89) and a high amount of heterogeneity, as indicated by the I 2 statistic (93.04%), suggesting that moderator analyses were appropriate. As hypothesized, measure type moderated the metacognitive deficit with homogenous effect for psychosocial functioning measures (Q = 9.81, I 2 = 19.47%, d = .94. 95% CI .58 to 1.2) and symptoms (Q = 19.87, I 2 = 0%, d = À1.07, 95% CI À1.18 to À.75). Further analysis found homogenous effects for MAS-A subscales as well as PANSS factors of symptoms. Conclusion: Our meta-analysis results illustrated a significant association between metacognitive deficits and both symptomatic and psychosocial functioning measures. These links suggest that the associations between metacognitive abilities and symptomatic outcomes are different from those between metacognitive abilities and psychosocial functioning measures. Intriguing hypotheses are raised regarding the role that metacognitive abilities play in both symptoms and psychosocial functioning measures of people diagnosed with schizophrenia spectrum disorders.
Schizophrenia Research, Aug 1, 2013
While research has paradoxically linked insight to greater emotional distress and depression in s... more While research has paradoxically linked insight to greater emotional distress and depression in schizophrenia, little is known why and for whom insight can result in depression. One possibility is that internalized stigma and deficits in social cognition and metacognition are risk factors for insight to convert to depression. To explore this possibility we assessed insight, depression, internalized stigma, social cognition and metacognition for sixty five persons with schizophrenia spectrum disorders. We then performed a cluster analysis based on insight and depression scores. Three groups were produced by the cluster analysis: Good insight/ Mild depression (n = 22); Fair insight/Moderate depression (n = 26) and Poor insight/Minimal depression (n = 17). As predicted, ANOVA comparing groups revealed the three groups differed in social cognition, and the metacognitive mastery aspect of metacognition. Those with fair insight and moderate depression reported more internalized stigma than those with poor insight and minimal depression. Persons with good insight and mild depression had higher levels of social cognition and metacognitive mastery than the other two groups. These differences persisted when controlling for neurocognition and symptom severity. These findings point to the possibility that future research should examine whether bolstering metacognitive and social cognitive capacities may have a protective effect as persons are assisted to achieve insight.
Frontiers in Psychiatry, Apr 13, 2023
BackgroundImpaired cognitive insight and increased self-stigma have been consistently reported in... more BackgroundImpaired cognitive insight and increased self-stigma have been consistently reported in individuals diagnosed with schizophrenia spectrum disorders, but little is known about its presence in individuals at ultra-high risk of developing a psychosis, although self-stigma is associated with transition.to psychosis. The current study examined whether self-stigma is already present in individuals at ultra-high risk of psychosis, and whether this is associated with impaired cognitive insight.Methods184 participants were recruited divided over three groups, namely individuals diagnosed with a schizophrenia spectrum disorder (SSD; n = 92, 34% females), individuals at ultra-high risk for psychosis (UHR; n = 43, 59% females) and general population controls (GPC; n = 49, 27% females). All participants completed assessments on demographic information (gender, age, education), and cognitive insight. In addition, participants with SSD and individuals at UHR completed a questionnaire on self-stigma.ResultsThe level of self-stigma did not differ between individuals at UHR and individuals diagnosed with SSD. Cognitive insight also did not differ significantly between the three groups, but the subscale self-reflection differed between the three groups [F(2,184) = 4.20, p = 0.02], with the UHR and SSD groups showing more self-reflection. Pearson’s correlation analyses showed that in individuals at UHR total cognitive insight and its self-reflection subscale were significantly associated with the alienation subscale of self-stigma, and in individuals with SSD self-certainty subscale of cognitive insight was significantly associated with stereotype endorsement.ConclusionFindings show that self-stigma was already present in the UHR phase, to a similar degree as in individuals with a diagnosis of a SSD, and is thus not dependent of previous experience of having a label of SSD. Cognitive insight in individuals at UHR of psychosis appears to be intact, but individuals at UHR showed more self-reflectiveness, and individuals at risk with high cognitive insight also experience high levels of self-stigma. Overall findings from our study suggest that pre-emptive interventions targeting self-stigma, while considering cognitive insight, are needed early on in manifestation of psychotic illness, preferably already in the UHR phase.
Journal of Psychotherapy Integration, Sep 1, 2021
Journal of Clinical Psychology
Growing awareness that many who are diagnosed with schizophrenia recover has spurred the developm... more Growing awareness that many who are diagnosed with schizophrenia recover has spurred the development of new psychosocial approaches to treatment. These new approaches include forms of individual and group psychotherapy whose focus extends beyond reducing symptoms and improving skills to subjective outcomes related to sense of self. This paper introduces an issue of In Session which presents six case reports which illustrating these approaches in differing international contexts. First, we explore the larger issues of subjective outcomes from schizophrenia. We then discuss each of the papers separately along with implications of these papers as a group for how treatment might promote the recapturing of a sense of self or place in the world.
Journal of Psychiatric Research
Background: Research suggests that in-session emotional experiences in psychotherapy promote both... more Background: Research suggests that in-session emotional experiences in psychotherapy promote both session and treatment outcomes across different clinical samples and treatment approaches. However, little is known about how this notion applies to clients with schizophrenia, who experience particular deficits related to emotional experience. To explore this question, we investigated the association between clients' emotional experience and their session outcome evaluations and metacognitive growth in a metacognitively-oriented treatment, Metacognitive Reflection and Insight Therapy (MERIT). MERIT is a recovery-oriented treatment approach for psychosis that focuses on recapturing a coherent sense of self and personal agency by enhancing metacognitive capacity. Method: Five-hundred-and-sixty-three sessions of 37 clients with schizophrenia who took part in an ongoing MERIT trial were analyzed. The Emotional Experience Self-Report (EE-SR) and Outcome Rating Scale (ORS) were collected on a session-by-session basis. Levels of metacognition ware assessed pre-and post-treatment using the Metacognitive Assessment Scale-Abbreviated (MAS-A) coding system. We used multilevel modeling to test our session-level predictions, and linear regression analysis for treatment-level predictions. Results: Greater emotional experience, expression, and regulation within a session were associated with better session outcome. Regarding treatment level, greater emotional experience was associated with improvement in metacognitive mastery. Conclusions: Our findings reveal that experiencing emotions in MERIT has significant implications for clients' subjective well-being during therapy sessions and for their ability to respond to psychological challenges using metacognitive knowledge. These findings lend weight to the idea that emotional experience is a key mechanism of change in metacognitive therapy for schizophrenia.
Clinical Psychology Review
Take-down policy If you believe that this document breaches copyright please contact us providing... more Take-down policy If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim.
Psychology and Psychotherapy: Theory, Research and Practice, 2021
ObjectivesTo promote functional recovery in persons diagnosed with a psychotic disorder, vocation... more ObjectivesTo promote functional recovery in persons diagnosed with a psychotic disorder, vocational interventions have emerged over the last few decades which range from sheltered employment to supported employment in the community.DesignUsing data from a 6‐month vocational rehabilitation programme, we examined whether assessments of the therapeutic alliance were related to the quality of work performed in this work placement. Our first hypothesis was that stronger alliances would be related to better work performance. Second, we expected that client assessments of the TA would better predict outcomes than therapist assessments. Third, we expected that the discrepancy between assessment scores from the client and therapist (client rating minus therapist rating) would be a better predictor for outcome than individual assessments by the therapists or clients.ResultsClients systematically rated the alliance higher than therapists. Modelling the data longitudinally, we found both therap...
Frontiers in Psychology, 2021
Many with psychosis experience substantial difficulties forming and maintaining social bonds lead... more Many with psychosis experience substantial difficulties forming and maintaining social bonds leading to persistent social alienation and a lack of a sense of membership in a larger community. While it is clear that social impairments in psychosis cannot be fully explained by symptoms or other traditional features of psychosis, the antecedents of disturbances in social function remain poorly understood. One recent model has proposed that deficits in social cognition may be a root cause of social dysfunction. In this model social relationships become untenable among persons diagnosed with psychosis when deficits in social cognition result in inaccurate ideas of what others feel, think or desire. While there is evidence to support the influence of social cognition upon social function, there are substantial limitations to this point of view. Many with psychosis have social impairments but not significant deficits in social cognition. First person and clinical accounts of the phenomenol...
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Papers by Ilanit Hasson-Ohayon