Growing Metacognition to Address the Negative Symptoms of Psychosis

Overview: Although some psychosocial interventions reduce delusions and hallucinations in conjunction with psychotropic medication, there are less that address negative symptoms and social functioning for psychosis survivors. We explore the evidence base for social-cognitive skills training (SCST), mentalization-building interventions, attachment-informed interventions, and metacognition-building exercises in reducing negative symptoms of psychosis.Proposal text: Psychosis, in addition to hallucinations or delusions, is also typically accompanied by negative symptoms (avolition, anhedonia, social withdrawal, difficulty showing emotions, alogia). Results from recent studies suggest that building social cognition, mentalizing abilities, and metacognition, may in turn reduce negative symptoms, increase self-compassion, increase felt safety in attachment relationships, and decrease self-stigma. This study aims to explore the evidence base for social-cognitive skills training (SCST), mentalization-building interventions, attachment-informed interventions, and metacognition-building exercises in reducing negative symptoms of psychosis and increasing felt safety in social relationships with others.

The social dimension of psychosis cannot be ignored. The current understanding of the etiology of psychosis has evolved from Kraepelin’s (1919) early model of Dementia Praecox to a complex, biopsychosocial model that recognizes psychosis as a disorder of fragmentation and biological processes that can be reversed through psychosocial means. Some social components that are risk factors for psychosis later in life include early childhood trauma, attachment insecurity, poor mentalization, poor metacognitive skills, and low social cognition.

Mentalizing is the awareness of motivations behind the self and others’ behaviors. Social cognition is another construct that has been described as important to target in treating the social domain of psychosis. Social cognition includes four domains: theory of mind, emotion processing, attributional bias, and social perception. Metacognition, distinct from mentalization or social cognition, is “a set of processes in which pre-reflective and reflective, embodied and cognitive experiences are, in the moment, interpreted and those interpretations are then in turn adjusted (or not) in response to what those experiences disclose.”

Perhaps the different perspectives on what needs to change within the social dimension of psychosis can be integrated to form an effective intervention to address negative symptoms. Social cognition indeed is not enough for people to have whole social satisfaction in their relationships: knowing how to interpret someone’s social cues cannot guarantee that the person will respond appropriately to them. Mentalizing is also not enough. All three components are found to be lacking the most in people who have experienced psychosis. It is difficult to implement social interventions that address psychosis survivor's need for increased social functioning

All of these definitions, the research in these areas for psychosis survivors, and a review of the strength of the evidence for the psychosocial interventions that target social functioning will be reviewed, along with implications for clinical practice of social workers. Where do social workers belong in the process of helping people with psychosis or other serious mental illnesses regain social functioning? Is psychoeducation enough?

The first block of time will be devoted to reviewing definitions and the various conceptual frameworks for social functioning of psychosis survivors. Next, I will review current psychosocial interventions in randomized controlled trials and the outcome measures for social functioning being used. Following, I will review evidence-supported strategies that social workers and social work clinicians can use for addressing the social component of psychosis. The remaining minutes will be for questions and for reflecting on the content.