Metacognitive Reflection and Insight Therapy (MERIT) was originally developed as an integrative recovery-oriented therapeutic approach to address the needs of people with a diagnosis of schizophrenia and other forms of severe mental illness. The approach, conceptualized as transtheoretical, aims to promote a more coherent and synthetic sense of self, through stimulating insight, sense of coherence, and metacognitive capacity. We argue that MERIT therapy, designed to facilitate peoples’ ability to form complex ideas about themselves and others and to use this knowledge to respond to psychological problems, has application in addressing deficits associated with bipolar disorder (BD), where there may be a significant injury to the person’s sense of self. That is, the therapy addresses the nascent sense of self in a context where disturbance of mood is dominant, and in relation to the experience of episodic manic episodes which may be understood as dissociative events, often associated with shame. The application of the therapeutic approach, which we term MERIT-BD draws upon MERIT’s primary principle of facilitating complexity and integration of the self, and additionally addresses shame, allowing for the facilitation of metacognitive capacity and insight in the context of finding the person. This approach will be illustrated with case vignettes illustrating the application of key components of MERIT-BD. Early findings drawn from a series of case studies are encouraging.
We experience ourselves and relationships with others through our feelings and moods. Mood thus plays a significant role in the ways in which we constitute the meaningfulness of our relationships with self and other. Bipolar mood disorders (BD) are understood as chronic biological “illnesses” characterised by dysregulated and often cyclical mood fluctuations spanning various degrees of depression or melancholia through to mania. From a phenomenological perspective, the experience of affect and mood, which lie at the core of BD, may be viewed as a form of relatedness, connecting body, self, and the world. Disturbances in our capacity to experience or modulate feelings and mood states, reciprocally governed by an impairment in meaning-making and intra- and interpersonal relatedness, lie at the core of persons’ experience of the disorder.
Impairments of insight was revealed in a study of 28 individuals hospitalised for treatment of mania. Insight was persistently impaired from admission through discharge, even where mania and other symptoms had remitted (Ghaemi et al., 1995). Impaired insight into one’s bipolar illness presents a common and major barrier to medication compliance, service engagement, and personal recovery (Novick et al., 2015). Poor insight, on the part of the patient, also contributes to the burden commonly experienced by partners of people with a diagnosis of BD and relationship breakdown. Behaviours such as a volatile relational style, poor decision making, and uncharacteristic risk-taking behaviour are commonly accompanied by limited insight into the impact of the disorder on both self and partners (Granek et al., 2016).
Clinical consensus dictates that primary treatment necessitates pharmacological stabilisation of acute mood episodes and subsequent maintenance to prevent recurrent episodes (Gabbard, 2014). The role of psychotherapy as an adjunctive therapy has primarily focussed on enhancing medication adherence. Contemporary approaches however aim to address the deficits associated with severe mental illness and focus upon recovery, a notion that has been broadened to extend beyond quantitative measurement of specific symptoms and deficits towards more holistic outcomes that privilege patients’ meaning making of experiences, sense of self, interpersonal functioning, and sense of autonomy (Lysaker & Klion, 2017; Lysaker & Lysaker, 2021; Leonhardt & Vohs, 2021). Metacognitive Reflection and Insight Therapy (MERIT) is one such integrative individual psychotherapy for the treatment of individuals with serious mental illnesses oriented to the promotion of sense and meaning-making of the challenges and potentials in individuals’ lives and to support them to direct their own recovery (Lysaker & Klion, 2017).
Current research recognises that a significant proportion of people with BD report experiences of adversity and have difficulties with metacognition (Popolo et al., 2017) and insight (Ghaemi et al., 1995). These deficits underpin the importance of fostering meaning-making as a significant part of the therapeutic approach in working with people who present with BD symptoms. The focus upon the facilitation of metacognitive capacity and addressing some of the unique features of BD is advocated as a means of promoting personal recovery and relapse prevention in people who are suffering BD.
The Structure and Expression of the Self
The self may be thought of in terms of an individual’s moment-to-moment subjective experience: ever shifting configurations of affects, positions, roles, values, and realities (Bromberg, 2013). In this respect, the self emerges from the multiplicity of continually evolving self-states (Bromberg, 2013). The self is both intersubjective and dialogical in that its existence is housed within the dialogue individuals have both within themselves and with others (Lysaker, & Lysaker, J. T. 2021); Hermans & Geiser, 2012).
Self states may be referred to as “I-positions” (Lysaker & Lysaker, 2021). These positions may be conflictual in nature, but at the same time, each I-position holds acknowledgement in relation to other I-positions which in turn, form an integrated and complex self-representation. Each self-state holds its own story and “as different voices involved in dialogical relationships, the I-positions exchange knowledge and experiences about their respective me, creating a complex, multi-voiced, narratively structured self” (Lysaker & Lysaker, 2021, p. 139). To function with authenticity and concern for both the self and others, self-states must function as part of a unified coherent whole (Bromberg, 2009).
The self thereby relies upon the metacognitive capacity to know, comprehend, and coherently articulate one’s inner mental states and processes across time, as well as interpret the mental states of others (Lysaker et al., 2012; Semerari et al., 2003). This integrative and synthetic function allows for a transitioning between self-states in response to others and the environment in a seamless manner which maintains a unified relationship between the various self-states as part of a functional whole, allowing for a sense of cohesion and temporal continuity (Bromberg, 2009; Lysaker et al., 2018; Semerari et al., 2003).Bromberg (2009) describes this transitioning as occurring through the process of normal dissociation.
Deficits in integrative metacognitive function results in a disorganised or dissociated mind: a self that is evident in an individual’s temporally discontinuous, incoherent, and fragmented narrative (Semerari et al., 2003). In other words, different self-states are defensively dissociated and transitioned between with rigidity, a process referred to as defensive dissociation (Bromberg, 2009).
The Structure and Expression of the Self in BD
In the case of BD, the conflicting nature of self-states can be even more obvious/extreme compared to people who do not evidence BD. Individuals’ present with a vulnerable self, comprised of self-states that are too highly conflictual to be reconciled by the mind to co-exist as part of an integrated whole (Bromberg, 2013). Additionally, people with a diagnosis of BD demonstrate higher negative and lower positive content within their overall self than healthy individuals (Taylor et al., 2007). High compartmentalisation and the defensive dissociative processes utilised to manage highly conflictual self-states in patients with BD, therefore serves to protect the individual from experiencing their self as persistently negative, as would occur in an integrated self which was predominantly constructed from negative content without sufficient balance of positive content. Compartmentalization and defensive dissociation thereby allow individuals to capitalise on their all-positive self-states which are, to them, a rare phenomenon. In support of these explanations, investigations into the organisation of the self in individuals with remitted BD have indeed revealed a prevalence of high degrees of compartmentalisation, the segmentation of all positive and all negative traits into different and distinct self-states, leaving these individuals vulnerable to severe mood fluctuations compared to more integrated individuals (Power et al., 2002; Taylor et al., 2007).
Based on these research findings, we argue that BD may be conceptualised as a disorder of the self in the sense that people with a diagnosis of BD may be characterized as holding a rigid mental structure comprised of highly discrepant and compartmentalised affective self-states. Therefore, in working with patients with BD, therapists must work with the patient to facilitate a continuous narrative that promotes resonance between the presenting compartmentalized self-states (Gabbard, 2014). Considering the important role of metacognitive capacity for a sense of cohesion as discussed previously, improving metacognitive capabilities of people with BD has the potential to facilitate a transition from defensive dissociation to normal dissociation.
Shame and Stigma in BD
The experience of shame is common in people who have a history of BD (Fowke et al., 2012). Shame is a self-conscious maladaptive emotion arising from a negative evaluation of one’s self against socially derived ideals which deeply permeates our sense of self (Tangney et al., 1995). Repetitive or intense affective shameful experiences may become embedded into the self, leading to a predominance of negative self-states. This may be reflected in a pervasive sense of inadequacy and a tendency to experience and enact aspects of shame in response to activating events (Kaufman, 1996; Pinto-Gouveia & Matos, 2011). Empirical evidence suggests that people with a diagnosis of BD have significantly higher levels of internalized shame than controls with no psychiatric diagnosis (Fowke et al., 2012).
The acquisition of internalized shame in people with a diagnosis of BD likely occurs throughout the lifespan from both developmental experiences, such as childhood abuse or neglect which are higher in BD populations than non-illness controls, and through shameful socialization experiences relating to BD pathology and its associated stigma (Fowke et al., 2012). As internalized affect and its associated narrative and imagery is central to shaping the self, shame attached to highly compartmentalized self-states in people with BD functions to promote defensive dissociation. Therefore, internalized shame must be identified and addressed therapeutically, as part of allowing emergence of more balanced self-states to emerge.
Background of MERIT and Application of MERIT to Patients with BD (MERIT-BD)
In this section, we first describe Metacognitive Reflection and Insight Therapy (MERIT; Lysaker & Klion 2017), which was conceptualized as a recovery-oriented approach with application to working with people presenting with symptoms of psychotic spectrum disorders. The approach proposes that the patient them self, in collaborating with a therapist, is required to make sense of the challenges they confront and determine how they might move toward and take charge of their own wellness. Then, we introduce an application of MERIT in BD (MERIT-BD), which we developed to address specific deficits associated with bipolar mood disorder. We will discuss the dimensions of experience associated with BD drawing upon research and a series of clinical case studies undertaken as part of a 12-month treatment trial in a university clinic with people diagnosed with BD.
The Role of Metacognitive Awareness and Insight in MERIT
Metacognition, a synthetic function, comprises four higher order processes: self-reflectivity, defined as an ability to understand, coherently describe, and appreciate the subjectivity of one’s own mind; understanding the mind of the other; decentration, defined as an ability to understand the minds of others’ from a non-egocentric perspective and appreciation of the hypothetical nature of these assessments; and mastery in working through and responding to challenging self-representations and experiences with effective action (Semerari et al., 2003). The deficits associated with a poor understanding of self and other is referred to as a deficit in insight. Within this context, metacognition describes the cognitive processes underpinning self-experience. By promoting metacognitive capacities, we can facilitate a spectrum of mental activities involving the person making sense of the challenges they face resulting from the condition which has led to them seeking assistance (Lysaker et al., 2013). MERIT approach assumes that therapist and patient can enter a space in which the reports by the patient (narrative episodes) can be thought about and understood by both therapist and patient, as part of an intersubjective and meaning-making process which in turn leads to insight.
Elements of MERIT
MERIT comprises eight elements, each of which facilitate metacognitive reflections shared by patient and therapist. The first six elements address the following: what the patient is seeking in the moment (i.e., the agenda), the patient’s experience of the therapist’s presence, thoughts, and actions (i.e., insertion of the therapist’s mind); specific events in the patient lives (i.e., eliciting narrative episodes); social and psychological challenges the patient is facing (i.e., defining the psychological problem); the patient’s relationship with the therapist (i.e., reflecting on the therapeutic relationship); and addressing current processes in the session (i.e., reflecting on progress). The final two elements (i.e., stimulating self-reflection and awareness of the other, and stimulating mastery) require the therapist to assess the patients’ maximal metacognitive capacity within the session. The therapist is encouraged to work with patients at an appropriate metacognitive level within reach of their capacity to achieve an improvement in their metacognition. This process facilitates the patient using metacognitive knowledge to respond to psychological and social challenges (Lysaker & Klion, 2017). MERIT is tailored to the specific needs of each patient, intentionally avoiding imposing a curriculum or set of predetermined activities which could hamper reflection and disrupt the development of understanding between patients and therapists (Lysaker & Klion, 2017).
The Application of MERIT in the Context of BD (MERIT-BD)
People who experience symptoms of BD are likely to have experienced mental states during which they experience problems understanding their own mental states and understanding and regulating their emotions, particularly during experiences of significant mood variation. Therefore, MERIT has a potential to help people with BD by focusing on improving metacognitive capacities. However, as discussed previously, therapists are encouraged to consider two important unique characteristics of the illness when working with patients with BD: defensive dissociation and shame. Specifically, in aiming to support patients with formulating more complex ideas about themselves, others, and the environment, MERIT can inform an approach in which the essential psychotherapeutic task in working with patients with BD, includes promoting the integration of fragments of the self, including shame, into a more coherent and continuous narrative to enhance insight, treatment compliance, and recovery (Gabbard, 2014).
MERIT may be viewed as a lens shaping the work of the therapist, as opposed to a therapy method. With this in mind, we argue that the approach may be expanded to address the phenomena of shame and of defensive dissociation, in people with a history of BD. The symptoms as reported by people with BD may be understood as a disruption to their capacity to negotiate and acknowledge highly conflictual self-states. The approach to the therapy requires an intersubjective meaning-making relationship between therapist and patient who struggle to make meaning of the disruptions associated with cyclical changes in mood states, which are often extreme to the point where the person may evidence psychotic experiences. It is through this process of engaging with the other and enhancing metacognitive processes that we promote self-management and witness, what we have termed, “finding the person” within a recovery-oriented paradigm.
MERIT-BD addresses the underlying self-structure in patients with BD through working towards a more integrated self: a more unified self, comprised of self-states that hold both positive and negative content and are meaningfully and consistently interconnected. The approach aims to find the person in the disorder by facilitating more elaborated and complex non-illness self-state representations, integrating positive and negative aspects of the self, delighting in the positive unseen aspects of the self to promote a balance of positive and negative aspects to resolve shame and remove the need for compartmentalisation, and bringing order and hierarchy among chaotic and overly complex manic and depressed self-states whether occurring sequentially or concurrently (Kraepelin, 1987).
Following the work of Lysaker et al. (Lysaker et al.2017), in their identification of three kinds of self-experience associated with schizophrenia, we wish to propose various self-experiences associated with bipolar mood disorder, which we term: poly-logical, superhero, and melancholic. That is, the poly-logical position is characterised by multiple self-state representations, or dialogical “voices”, often co-occurring during which the individual may engage in hyperactive behaviour, engaging in multiple tasks, with significant difficulties in focussing upon goal-directed behaviour. The superhero self-experience represents the expression of grandiose self-states which may be associated with mania. We think here of people with a diagnosis of BD who describe experiences, such as attempting to call the Queen of England or the White House, and more generally, have an inflated sense of esteem. It involves engrossment in positive compartmentalised self-states that appear split off from the rest of the self. The melancholic position is dominated by a profound withdrawal from the world, experiences of derealisation, with surrounding objects losing their appeal. It involves the immersion in negative compartmentalised self-states. In extreme instances the person may become preoccupied with death, annihilation, and catastrophe which may be associated with guilt, pain, and deprivation (Sass & Pienkos, 2013).
Applying MERIT Elements with the Addition of Two Primary Tasks
MERIT-BD extends upon MERIT’s eight elements to include two primary tasks centred around the theme we have designated as “finding the person within the patient”. That is, the therapy, drawing upon the contribution of Lysaker & Klion (2017) and Bromberg (2013), works toward collaborating with the patient to identify their own voice and a clear sense of themselves as separate from their diagnosis. While the idea of “finding the self” is abstract, the intent, from a therapeutic stance, is consistent with Symington’s reference to love in psychotherapy, not in the English language understanding of romantic affection, but a sense of passion, delight, or regard for the other, referred to as a contemplative act. “In this act, the person marvels at the other. It is in this act, the act of contemplation, that there is a focused wonder at the quality of the other” (Symington, 2007, pp. 1421). Just as a child requires to see their value, emotions, and potential for growth reflected to them in their carer’s eyes, the therapist provides hope and a more positive structuring of the self. That is, through the relationship and mutual recognition, whether this is in terms of aligning with, delighting in, or simply acknowledging various aspects of the person, he or she may well experience a sense of hope and gratification in relation to their experience of self, emerging through the therapeutic relationship.
Several elements of MERIT are significant in contemplating the therapist attending to the patient’s sense of what they are experiencing as it is happening within the session and stimulating reflections about self and others as mechanisms for finding the person of the patient (Lysaker & Klion, 2017). In our experience, the task of therapy is to think with the patient about narrative episodes revealed through their agenda and may include emotional distress or pain and identify those elements of self (or self-states) which may be critical to their sense of identity or reveal previously hidden aspects of self.
In articulating this process, we explicate two primary tasks for the application of MERIT-BD: facilitating complexity and integration of the self, and addressing shame and stigmatization. These two acts of contemplation lead to an acknowledgement of the self of the person and lay the foundations for facilitating metacognition and insight towards the overall aim of finding the person.
Facilitating Complexity and Integration of the Self
It is common for people with a diagnosis of BD to relate a self-narrative saturated with ideas around their diagnosis, management of the disorder, and concerns related to fears concerning future episodes. For example, one patient introduced herself in terms of: “I have bipolar mood disorder” prior to sharing anything about herself or the issues she may be dealing with. The diagnosis took precedence in establishing her identity, though the context may have influenced her presentation. Furthermore, patients with BD will often describe episodes of affective instability accompanied by mood congruent delusions. Illness self-states frequently dictate the therapeutic encounter, necessitating the therapist and patient engaging in an intersubjective exploration to bring to light and elaborate the unseen or unacknowledged non-illness and vital aspects of self.
The therapeutic process involves a discovery of “the other” as a person, independent of the symptoms in the life of the patient. The therapeutic approach is guided by the stance of the therapist engaging with the person (we refer to “patient”, from the Latin term patio, “to suffer”), not as an expert and “doing to the other” but as a collaborator seeking to gain an understanding of the life-world of the other. The approach is based upon the assumption that sense of self emerges through the relationship between self and other. The clinical process in MERIT-BD is “experience-driven” in the sense that the therapist seeks to draw upon the here and now experience of the relationship with the patient to promote a more coherent sense of self.
In addition to the foundational principles of MERIT (Lysaker & Klion, 2017), MERIT-BD is an integrative approach drawing upon evolutionary theory, attachment theory, and trauma and dissociation theory. The therapist provides an opportunity for the patient to give expression to self-states (subjective experience) and recapture metacognitive capacities which may have been lost as part of their illness experience. The approach draws upon relational episodes, recognising that self-positions are socially positioned within the interpersonal life of the patient. Drawing upon the notions of enhancing metacognitive functioning through the “sharing of mind” and “insertion of mind,” the therapist can provide nuanced experiences which target self-reflectivity titrated to the patient’s capacities at the time, and not exceeding their capacity to integrate experience (Lysaker & Klion, 2017). The therapist thus seeks to promote awareness of self-state experience regardless of the fragmentation which may have been part of the dissociative aspects of the illness experience. Over time, the therapist engages with the patient to develop greater capacity to integrate experiences and information about themselves and form more coherent ideas about self and other, and to use this knowledge to negotiate the challenges which they may face in their process of recovery (Lysaker et al., 2018).
Patients with BD routinely refer to experiences characterized by reality and fantasy, particularly in relation to experiences of mania or melancholia. Engaging with the mind of the other is seen as critical in promoting recovery. That is, the person may experience so called fantasies, involving self-state configurations previously described as superhero, melancholic or poly-logical. For example, the superhero self-state may involve exaggerating one’s own achievements and expressing disdain for others or assuming grandiose self-states. In the instance of grandiose ideas, part of the therapeutic exploration may involve working with the patient to become aware of those parts of self which identify as being infallible or invulnerable, often part of normative developmental histories and also those parts which contradict their sense of superiority. The process of identifying, owning, and integrating potentially disavowed aspects of self into one’s continuing sense of self is consistent with Gabbard’s (2014) notion of constructing narrative continuity through the amalgamation of the patient’s self-fragments.
In keeping with both MERIT and MIT, MERIT-BD considers the intersubjective process emerging within the therapeutic relationship as critical in enhancing metacognition, which in turn, contributes to complexity of self and integration of disavowed aspects of self (Salvatore et al., 2021). Salvatore et al., describing the treatment of persons with personality dysfunction, highlight the ways in which the therapist, from the very first moments with the patient, notes the residual healthy self-aspects of the patient, regardless of the patient’s level of distress, and attempts to connect the patient with those vital aspects of self that are regarded creative and contribute to one’s sense of humanity (Salvatore et al., 2021 ), and which may well have been obscured by aspects of their disorder.
Similarly, in collaborating with people with a diagnosis of BD, there is an argument that the “flight into mania” may represent a form of dissociation and increase the person’s capacity to bear and process internal conflict. The patient may draw upon a capacity to be mentally playful and creative within the structure provided by the therapist, who is experienced as non-intrusive and curious, to experience their own mental state and develop a greater capacity to reflect and form their own images and thoughts, as they engage in being both alone and in the presence of another (Bromberg, 2001). Through this process, the patient is encouraged to appreciate the complexity of their mental state, and to use their relationship with the therapist to achieve a capacity to observe self, referred to as decentration (Lysaker & Klion, 2017). The patient is thus more self-contained, and able to view themselves from the therapist’s perspective. The process is fostered by the therapist remaining sensitive to both the vulnerability and the complexity of the patient’s mental states.
A patient we will refer to as Janice presented with alternating self positions, which we have termed melancholic, and superhero self positions. She presented with religious ideas related to her having a special mission on earth and the power to “save” others from some form of damnation. This alternated with periods of melancholy where she was unable to get out of bed and attend to basic daily tasks. Her history revealed early parental separation, and chronic childhood maltreatment and neglect stemming from maternal mental health problems which were theorized to have impacted on Janice’s early development. Her vulnerable self-states relating to her sense of vulnerability remained dissociated as the intolerable shame that accompanied these self-states resulting in a sense of non-existence through expectations of not being acknowledged or visible in the eyes of the other.
Patient: I had a terrible time as a child. I can remember being tied to a tree; it was awful. Eventually I was removed from my family. I rely on “B” (her current partner). I just want to be held. I don’t want intimacy.
Therapist: I am wondering what that must have been like? I can only imagine feeling so vulnerable, and what could have happened?
Patient: It was easier to imagine that I did not exist.
Therapist: I am trying to imagine you wishing that you did not exist?
Throughout the therapy process, the therapist was able to engage with Janice in joint reflection and narrative elaboration (involving therapist being transparent with patient on their mind) to bring awareness to that “which was previously too unbearable to bear” (psychological challenge) and the ways in which she would cope with the challenge by escaping into her own fantasies and feelings of omnipotence (demonstrating her ability for mastery at the time involving passive avoidance strategies). By owning feelings of powerlessness as well as her capacity to think of and identify with others exposed to similar deprivation (through therapist stimulation of understanding of self and other), the therapist fostered more complex ideas of self and other (facilitating complexity and integration of the self). The therapist and patient co-created a space within which two dimensional descriptions of self were enhanced and emerged as more complex and coherent. An earlier description of self, characterized by symptoms associated with her disorder including her delusions, was transformed into a newfound sense of coherence and capacity to think of self and other, and to draw upon her new perspective to make sense of and manage (thought enhanced ability for mastery involving facing a challenge) which previously had been warded off.
Distinctive features of MERIT-BD were evidenced in the therapist facilitating decentration, through fostering the patient’s capacity to gain an understanding of their progress, particularly during times of withdrawal and despair. The patient was thus better able to identify self-descriptions, when they were not in despair, and they gained an appreciation of the cyclical nature of their changes in mood, often appearing as endless in the moment. The patient’s apparent limited capacity to appreciate the unfolding of time was challenged directly by the therapist with their ability to link periods of wellbeing and bring this knowledge into the present during periods of melancholia, thus promoting integration of self.
In one instance, one of the authors asked a patient who experienced severe depressive states, often associated with suicidal ideation, to reflect upon what had been most helpful in the therapy. He recalled a single session some months previous, during which he was suicidal, where the therapist drew a simple diagram on a white board reflecting the course of his experience and highlighted the fact that on previous occasions, he had made a good recovery and that his depressive mood would remit once again. This process facilitated his capacity for decentration.
Addressing Shame and Stigmatisation
Shame results in the destabilization and invalidation of the self and the promotion of defensive dissociation, resulting in a loss of identity. Therefore, the process of addressing fragmentation and dissociation of the self in patients with BD cannot occur unless shame is addressed. Addressing shame in the context of BD is particularly complex and needs to draw upon our understanding of both the patient’s responses to shame, and to the therapists’ tendency to ward off shame within the therapeutic context. When shame is incorporated into the self, it generally develops in the context of being in relation with another and therefore is enacted as opposed to being expressed. The capacity to master and heal the self from the influence of shame, when working with patients with BD who have high levels of internalized shame, must therefore occur within the bounds of a reparatory relationship; one that is qualitatively different from but functionally the same as the secure-giving relationship that provides for optimal development (Kaufman, 1996).
To mirror the relational processes underlying the development of the self, the therapeutic relationship in MERIT-BD privileges intersubjectivity: the mutual construction and understanding of subjective experience (Beebe et al., 2003, Stern & Hirsch 2018). It is this interface between each of the dyad’s shifting self-states, that patient’s previously conflictual compartmentalized self-states, particularly those that are shame-bound, can move towards co-existence and new adaptive ways of experiencing the self can be entertained (Bromberg, 2013). Attendance to in-the-moment intersubjective relational processes is foundational to the MERIT approach. That is, through open discussion of these processes and the sharing of minds, individuals may gain capacity in identifying, naming, and making meaning of their internal states of mind (Hamm et al., 2021). Through the repetition of bringing shame to light in this manner and the mutual holding and experiencing of shame, we facilitate a reshaping of a more adaptive self.
Working with shame requires attunement to the patient’s shifting states and a particular therapeutic stance from the therapist. The phenomenology of BD is complex, as people experience “uncharacteristic thoughts and behaviour” which are often attributed to an expression of their “condition.” However, as these behaviours are frequently in stark contrast to an individual’s and significant other’s socially derived expectations and ideals, such behaviour frequently results in deep feelings of shame. Shame may be activated when patients with BD in a euthymic state refer to periods of past mania. For instance, we recall the presentation of a married male patient, referred here to as Stanley, who enjoyed a high-status position and presented with BD. Stanley had previously reported a history of being dismissed by family members as “crazy” from his teenage years and his wife had also turned to using this term towards him within her experiences of severe hurt and frustration.
Adopting what we have termed superhero self-experience, Stanley recalled periods of compulsive and copious consumption of pornography and engaging with sex workers with an uncharacteristic grandiose attitude. This allowed him to engage in these activities without any conscious concern regarding his partner having full knowledge. Whilst he attributed these behaviours to manic episodes, he also expressed awareness of the self-discrepancy between his manic self and his ideal self as a “good” man and husband resulting in elevated levels of shame. For example, in one session as Stanley spoke of the contribution of his previous manic episodes to his marital breakdown whilst exhibiting signs consistent with affective shame: his voice trailed off, he averted his eyes, and he became quiet for a moment. At this point it was important for the therapist to attune to the internalized shame underpinning Stanley’s withdrawal and being reenactment within the therapeutic dyad.
The discussion and ownership of Stanley’s manic behaviour presented him with both the risk of shameful exposure, resulting in harsh criticism and interpersonal disconnect, and simultaneously shame in seeking to own the pain associated with his experience which in turn may have triggered earlier experiences during which he compared himself to others. It was a bind that trapped Stanley alone in his shame, shut off from the interpersonal connection and unable to reconnect without the assistance of the other. Understanding the complexity of such interactions, both interpersonally and intrapersonally, poses specific challenges to a MERIT informed therapist. The relational component of MERIT comes to the fore as it is through the relationship itself that the patient can recognize and experience more constructive self-states, relating to awareness of both self and to others. Identifying, naming, and bringing potentially unformulated shameful experiences to consciousness within the context of a strong therapeutic relationship may reduce the need for defensive denial of illness self-states fostering an environment more conducive to the development of metacognitive awareness, comprising development of insight and the emergence of a more genuine and integrated sense of self. Adopting a stance derived from MERIT-BD, the therapist spent time exploring the nuances of experience and more particularly, the self-states which led to the behaviour underpinning his sense of regret (agenda). In the above instance, the therapist worked towards enhancing Stanley’s capacity for metacognition. Through joint reflection, Stanley was encouraged to give thought to the dissolution of his marriage (narrative analysis), which was related, in part, to his behaviour while manic. To this degree, he was encouraged to gain a greater capacity to appreciate his own mental state, and the mental state of the other (stimulating of understanding of self and other). There were aspects of his behaviour which he experienced as “being out of control” and shameful (shame, psychological challenge). Confronting such states, and appreciating the experience of the other (i.e., requiring higher capacity for mastery), is complex, as shame is often deeply embedded within the premorbid character structure and results in a complex dynamic in which manic defenses and/or depressive states involving withdrawal might serve a protective function during times of acute distress (facilitating complexity and integration of the self).
When shame is activated and enacted within the therapeutic space, it inevitably creates an intersubjective space where shame is felt by both parties (Bromberg, 2013). In this space, the therapist may experience an urge to avoid shame through therapeutic passivity, focusing on technique, or intellectual discussion. However, such responses prevent the patient from experiencing the entirety of their shame within the confines of a safe relationship to allow for a corrective experience. Shame avoidant measures by the therapist, though generally inadvertent, reinforces the patient’s shame around experiencing a need from the other through further repetition of past experiences. The therapist must be forthcoming with a willingness to sit in the discomfort of the patient’s subjective shame with them, as if offering their own mastery as a prosthetic, to support the client to recognize, acknowledge, and fully experience their shame. This is necessary to work towards an acceptance of their shame bound self-states, identify the sources of their shame, and return shame to its appropriate origins. The therapist cannot possibly provide an effective holding function to assist clients to tolerate the necessary experiencing of shame if they are not able to feel and master their own (Kaufman, 1996). It is acknowledged by several authors that the therapist’s shame may have a significant impact upon the course and outcome of therapy (Covert et al., 2003; Leith & Baumeister, 1998; Kaufman, 1996). The therapist thus needs to be aware of and acquire mastery of their own shame to provide this function.
Application of MERIT-Informed Perspective Across Diagnoses
In comparing the application of working from a MERIT-informed perspective across patient groups with a diagnosis of schizophrenia, and with bipolar mood disorder, there are many commonalities and some differences. In both cohorts, the therapist draws upon the eight elements of MERIT with a focus upon facilitating metacognitive capacity, with the therapist providing understandings of what the patient has communicated, both overtly in terms of what is expressed and covertly, in terms of context, tone and body language. In this way, the therapist utilizes dialogue to foster sense of self and narrative coherence. In addition, the therapist adds to two primary tasks, which acknowledge the characteristics associated with a diagnosis of BD. That is, the therapeutic approach is interpersonal but also focusses upon the key aspects of the phenomenology of people who have experienced manic episodes. In this way, the therapist is sensitive to the compartmentalization of defensively dissociated conflictual self-states, often against a background of shame.
MERIT-BD builds upon the eight elements which constitute MERIT by incorporating two primary tasks to assist the therapist and person to challenge the shame and the potential dissociation associated with defensive dissociation, in promoting coherence and metacognitive capacity. We acknowledge the fundamental assumption that the therapy draws upon “two minds,” that is, the patient and the therapist, to work towards the creation of mind, as constituted by the emergence of metacognitive capacity in the context of the relationship between patient and therapist. The first six elements of MERIT continue to focus on the here and now, in seeking to engage the patient with their priorities in a context where they exercise a sense of agency in deciding on the priorities of the session. This may well relate to behaviours or clusters of symptoms, and at times, may be a request for information or seeking reassurance (agenda). The therapy process may well focus on the patient’s experience of the therapist’s presence, thoughts, and actions, but more likely, will focus upon specific events in the patient’s life (i.e., narrative episodes). In this regard, we have found the core conflictual relationship theme (CCRT) methodology useful in exploring the tasks underpinning the approach outlined, that is, to assist the therapist and person to challenge shame and defensive dissociation. The therapist explores repetitive relational patterns, identifying needs and wishes, and exploring the person’s context (Luborsky, 1990). Where patients have a history of mania, responses of self are often characterised by an unstated sense of shame, or fear of relapse. The process of identifying patterns lends itself to promoting metacognitive awareness and narrative complexity. This approach is particularly relevant in the context of the 4th element, referred to as an exploration of the social and psychological challenges faced by the patient. The 5th element, the patient’s relationship with the therapist, provides an additional opportunity to enhance awareness of self, as both therapist and patient give voice to their “here-and-now awareness of the thoughts, feelings and fantasies which get played out in the therapeutic relationship. At times, these may be grandiose and at other times quite modest, yet both “poles” provide opportunities for the person to gain a sense of self states, the ways in which these states may vary, and the opportunity to seek greater integration of these states. The description provided by Lysaker & Klion (2017) of the therapist “sharing their mind” is particularly apt in fostering meta cognitive awareness in response to meaning making in the context of the relationship being enacted in the therapy space.
We recognize that our clinical experience in the formal application of MERIT principles in collaborating with people from this population is limited. Generalizations drawn from a small number of case studies need to be treated with caution. Nevertheless, the case studies referred to provide support for the use of MERIT informed by the principles articulated above.
MERIT-BD draws upon the basic structure of MERIT but considers the significance of defensive dissociation required to maintain highly conflictual self-states and the sense of shame which may underpin the recovered sense of self. We have proposed that symptoms associated with BD can be considered as a form of dissociation and fragmentation of self. From this perspective, people with a diagnosis BD struggle with meaning making, a sense of shame and feeling stigmatised. The approach described draws upon a MERIT-informed framework in working with people with a diagnosis of BD. In the examples cited, we demonstrate the ways in which we were able to augment MERIT by incorporating two key dimensions which we termed facilitating complexity and integration of the self, and addressing shame and stigmatization, leading to the process of facilitating metacognitive capacity and insight.
In contrast to clinicians who advocate a psychoeducation role for practitioners as the primary psychological intervention collaborating with this cohort (Weiner et al., 2022) we return to Kraepelin’s famous 1899 text in which he referred to endogenous psychoses, one of which was manic-depressive psychosis (Kraepelin, 1987), later referred to as bipolar disorder. Kraepelin (1987) noted the cyclical nature of the disorder characterized by mixed affective and volitional states, and furthermore, that such states may occur at the same time. Within this context, we have argued for the importance of identifying the continuity of the person, and the role of sense-making and stimulating metacognitive activity to promote a more coherent sense of self. We further suggest that the delusions associated with manic states my provide a foundation for assessing aspects of self and that the psychotic features of the disorder may be understood in terms of their function and by inference, the protection they provide to the person’s sense of self. Adopting a non-judgmental therapeutic stance to delusional content provides an opportunity for bringing aspects of self into the therapeutic relationship, and the option of integrating parts of self into patients’ relationships in their social context.
There is considerable debate on the value of psychotherapy in the management of people with a diagnosis of BD, underpinned by genetic evidence supporting a genetic vulnerability to BD, and the advent of mood stabilizing drugs which have been shown to be highly effective in managing mood in people with a diagnosis of BD. We do not wish to enter a debate or even suggest that a psychotherapeutic approach is a panacea and may replace other forms of management, but advocate for, what we have termed, finding the person in the disorder, and adopting key principled derived from MERIT to support people with a diagnosis of BD.
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Schweitzer, R., Sonnenburg, C. & Komandur, P. Finding the Person in the Disorder: Adapting Metacognitive Reflection and Insight Therapy for Bipolar Mood Disorder (MERIT-BD). J Contemp Psychother (2022). https://doi.org/10.1007/s10879-022-09563-6
- Bipolar Mood Disorder