What is the Metacognitive Reflection and Insight Therapy?

MERIT is a model of psychotherapy developed by Paul H. Lysaker, Ph.D., based upon research suggesting that individuals who experience psychosis have difficulties forming a sufficiently integrated sense of self and others. Traditional views of recovery in psychosis have often emphasized gaining insight into symptoms and staying adherent to medication. Although medication can certainly be a useful tool, symptom management and skills training alone may not fully support the deeper, internal shifts that many people identify as central to their healing.

Research in recent years has increasingly noted the central role that an individual's relationships, community belonging, and sense of overall purpose play in the healing process. This raises an important question: how can therapy help someone strengthen their sense of self, reclaim their agency, and make meaning out of their experiences?

MERIT was developed in response to this need. MERIT is an integrative, person-centered psychotherapy designed to address the underlying processes that support meaningful growth. It focuses specifically on metacognition: the set of cognitive abilities that allow a person to understand their own thoughts, feelings, intentions, and experiences, as well as those of others. These capacities enable people to develop a flexible and evolving understanding of themselves in the world.

Core components of MERIT:

Centers the whole person rather than symptoms alone
Builds metacognitive strength to support clearer self-understanding
Encourages personal meaning-making instead of prescribing beliefs
Supports a renewed sense of agency in daily life
Respects each person’s lived experience and individual path to recovery
Designed for complex and subjective experiences such as those found in psychosis

The Eight Elements of MERIT

MERIT organizes its therapeutic approach into three groups of elements: Content, Process, and Superordinate, with each supporting the development of metacognition in people experiencing psychosis.

Content Elements:

Helping individuals explore what matters to them

1. Understanding the Person’s Agenda

Therapist and client work together to clarify the client’s current wishes, needs, and concerns, even when these may seem conflicting or unclear.

2. Exploring Reactions to the Therapist’s Reflections

The individual has space to express their thoughts or emotions about what the therapist says or observes during the session.

3. Focusing on Lived Experience

Rather than staying abstract, the conversation centers on the individual's real-life experiences and the unfolding “story” of their life.

4. Identifying Psychological Challenges Together

Client and therapist collaboratively recognize the key emotional or psychological struggles the client is facing.

Process Elements:

Reflecting on how therapy itself is unfolding

5. Discussing the Therapeutic Relationship

The client and therapist openly discuss their interactions and the relational space where reflection occurs.

6. Noticing the Impact of the Session

The client reflects on how the session affects them—emotionally, cognitively, or physically—and acknowledges any changes.

Superordinate Elements:

Supporting metacognitive growth in a paced, sustainable way

7. Matching Metacognitive Capacity (Self and Other Reflection)

Therapist interventions are tailored to challenge the client just enough, with an emphasis on never overwhelming their ability to think about thoughts, feelings, and perspectives.

8. Supporting Mastery at the Right Level

Interventions related to coping, decision-making, or responding to life challenges are tailored to the client’s current ability to utilize metacognitive knowledge.

MERIT does not direct clients to adopt certain beliefs or follow a predetermined therapeutic path. Instead, it:

builds the ability to reflect on one’s own thinking,
encourages a deeper understanding of self and others, and
supports the creation of personally meaningful interpretations of experience.

Just as physical therapy strengthens muscle groups through gradual practice, MERIT strengthens metacognitive abilities through guided reflection at increasingly complex levels. Outcomes are evaluated not by whether a specific belief or skill is achieved, but by whether clients can integrate information and form broader, more coherent meaning in their lives.

Sources:

Lysaker, P. H., Gagen, E., Klion, R., Zalzala, A., Vohs, J., Faith, L. A., Leonhardt, B., Hamm, J., & Hasson-Ohayon, I. (2020). Metacognitive Reflection and Insight Therapy: A Recovery-Oriented Treatment Approach for Psychosis. Psychology Research and Behavior Management, 13, 331. https://doi.org/10.2147/PRBM.S198628

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Metacognitive Reflection and Insight Therapy (MERIT)