Metacognitive Reflective and Insight Therapy for People in Early Phase of a Schizophrenia Spectrum Disorder Jaclyn D. Hillis, 1 Bethany L. Leonhardt, 3 Jenifer L. Vohs, 3 Kelly D. Buck, 2 Giampaolo Salvatore, 4 Raffaele Popolo, 4 Giancarlo Dimaggio, 4 and Paul H. Lysaker 2,3 1 University of Indianapolis 2 Richard L. Roudebush VA Medical Center 3 Indiana University School of Medicine 4 Center for Metacognitive Interpersonal Therapy Schizophrenia often involves a loss of metacognitive capacity, the ability to form complex and integrated representations of self and others. Independent of symptoms and neurocognition, deficits in synthetic metacognition are related to difficulties of engaging in goal-directed activities in social and vocational settings. Within this backdrop, we provide a case report of the effects of Metacognitive Reflective Insight Therapy (MERIT) that assisted a patient suffering from first episode schizophrenia during 2 years of individual psychotherapy. A total of 8 elements of MERIT that stimulate and promote metacognitive capacity are presented. As illustrated in this report, these procedures helped the patient move from a state in which he had virtually no complex ideas about himself or others to one in which he had developed integrated and realistic ideas about his own identity and the identity of others. He then could use these representations to understand and effectively respond to life challenges. C  2014 Wiley Periodicals, Inc. J. Clin. Psychol.: In Session 71:125–135, 2015. Keywords: Schizophrenia; first episode psychosis; psychotherapy; recovery; metacognition; cognition Introduction A limitation of models of schizophrenia that focus on discrete and observable symptoms related to neurocognitive and psychobiological processes is that they risk portraying people with this condition as passive entities subject to biological and social challenges, rather than as beings in the world who have to make meaning out of these challenges and life itself (Lysaker, Bob et al., 2013). In response, new paradigms have been proposed that focus on the interaction of psychological and subjective processes that influence outcome. Building on Bleuler’s (1950) suggestion that capacity for goal-directed behavior is lost as a result of a disturbance in the ability to synthesize complex ideas about oneself and others, deficits in metacognition have been proposed to underlie disability in schizophrenia (Lysaker & Dimaggio, 2014). Metacognition is a psychological function that comprises a spectrum of mental activities that involve thinking about thinking. It refers to mental activities ranging from discrete acts, in which people recognize specific thoughts and feelings, to more synthetic acts, in which an array of intentions, thoughts, feelings, and connections between events are integrated into larger complex representations (Lysaker et al., 2013; Semerari et al., 2003). Although metacognition has been linked with social cognition (Pinkham et al., in press), more synthetic forms of metacognition are assessed by analyzing discourse and focus on the recognition of basic elements of experience and their synthesis into complex wholes rather than the accuracies of specific judgments. Applied to schizophrenia, it has been proposed that loss of metacognitive capacity leaves people without a larger sense of the meaning of past and current events as well as compro- mised abilities to manage life challenges. Metacognitive deficits may represent a unique path to Please address correspondence to: Paul Lysaker, Roudebush VA Med Center (116A), 1481 West 10th Street, Indianapolis, IN, 46202; e-mail: plysaker@iupui.edu JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 71(2), 125–135 (2015) C  2014 Wiley Periodicals, Inc. Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.22148