Elements that enhance therapeutic alliance and short-term outcomes in metacognitive reflection and insight therapy: A session-by-session assessment

Psychiatr Rehabil J. 2020 Dec;43(4):318-326. doi: 10.1037/prj0000415. Epub 2020 Apr 9.


Objective: Preliminary evidence has found metacognitive capacity is associated with therapeutic alliance and with other outcomes in psychotherapy among persons with schizophrenia. The current study explored: (a) before to after changes in clients' metacognition capacity following Metacognitive Reflection and Insight Therapy (MERIT) and (b) whether the use of specific therapeutic elements of MERIT were followed by higher ratings of therapeutic alliance at the end of each session as well as with short-term outcome as measured prior to the next session, in a session-by-session intensive data collection.

Method: Two hundred twenty-one sessions of 10 completers with schizophrenia who took part in an ongoing MERIT trial were analyzed. Measures of therapeutic alliance (short version of the Working Alliance Inventory), general outcome (Outcome Rating Scale), and metacognition (Metacognition Assessment Scale-Abbreviated) were used.

Results: Findings showed significant change in 2 domains of metacognition, self-reflectivity and mastery, following therapy. In addition, the presence of 2 specific MERIT elements, the introduction of the therapist's mind and reflecting on the progress in therapy within a given session, were related to better outcomes in the following week. Finally, reflecting on the progress was also followed by higher therapeutic alliance.

Conclusions: Metacognitively oriented therapy may positively affect both therapeutic alliance and short-term outcome. Specifically discussing the therapist's and client's experiences of what is occurring in therapy may positively affect short-term outcome and could be applicable to other psychotherapy approaches. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Trial registration: ClinicalTrials.gov NCT03427580.

Publication types

  • Clinical Trial

MeSH terms

  • Adult
  • Cognitive Behavioral Therapy*
  • Female
  • Humans
  • Male
  • Metacognition / physiology*
  • Middle Aged
  • Outcome Assessment, Health Care*
  • Psychiatric Rehabilitation
  • Schizophrenia / physiopathology*
  • Schizophrenia / rehabilitation*
  • Therapeutic Alliance*
  • Young Adult

Associated data

  • ClinicalTrials.gov/NCT03427580