Div Classtitlemechanisms of Change in Psychotherapy For People Diagnosed With Schizophrenia The Role of Narrative Reflexivity in Promoting Recoverydiv PDF

Mechanisms of Change in
Psychotherapy for People Diagnosed

with Schizophrenia: The Role of
Narrative Reflexivity in Promoting
Recovery
Melissa Greben, Robert D Schweitzer, and Rebecca Bargenquast
School of Psychology and Counselling, Queensland University of Technology, Australia
N arrative reflexivity was investigated as a potential mechanism of thera-

peutic change during a 1218 month trial of Metacognitive Narrative
Psychotherapy for people diagnosed with schizophrenia. Participants were nine
adult clients (8 male, 1 female) aged between 2565 years (M = 44, SD = 12.76)
with a diagnosis of schizophrenia consistent with DSM-IV criteria and seven
female provisional psychologists aged between 2529 years (M = 26.8 years,
SD = 1.47 years). Recovery and narrative reflexivity were measured at three
time points using the Recovery Assessment Scale (RAS) and the Narrative Pro-
cesses Coding System (NPCS). Results were reported descriptively due to limited
sample size (n = 9). The majority of clients (n = 7) reported an increase in recov-
ery over the course of treatment. For six clients, an overall increase in recovery
was associated with an increase in narrative reflexivity. This study provides pre-
liminary support for narrative reflexivity as a potential mechanism of therapeutic
change in the psychotherapy of people diagnosed with schizophrenia.
Keywords: recovery, narrative reflexivity, metacognition, schizophrenia, dialogical
theory, mechanism of change
Schizophrenia as a Disorder of Sense of Self

Schizophrenia has been conceived by researchers and clinicians from diverse orien-
tations as being heterogeneous with a common feature of disturbance of the self.
Disturbed self-experience was included in the diagnostic criteria for schizophrenia as
recently as DSM-III (APA, 1980), and has been understood using psychodynamic,
humanistic and postmodern theories of self (Lysaker & Lysaker, 2010; Sass & Parnas,
2001). A disturbance in sense of self has been described as an enduring source of agony
and is experienced independently from other clinical symptoms in people diagnosed
with schizophrenia (Lysaker & Lysaker, 2002). As such pharmacological treatments
which commonly target symptoms are not sufficient to facilitate recovery (Henderson,
2013) and the role of individual psychotherapy has emerged as increasingly important
Address correspondence to: Associate Professor Robert Schweitzer School of Psychology and
Counselling, Queensland University of Technology, Kelvin Grove, Queensland, Australia 4059.
Email: r.schweitzer@qut.edu.au Phone: +61 7 3138 4617 Fax: +61 7 3138 0486
Australian Journal of Rehabilitation Counselling 1

Volume 20 Number 1 2014 pp. 114. C The Author(s), published by Cambridge University Press
on behalf of Australian Academic Press Pty Ltd 2014. doi 10.1017/jrc.2014.4
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MELISSA GREBEN, ROBERT D SCHWEITZER, REBECCA BARGENQUAST
in facilitating recovery from schizophrenia (Davenport, Hobson, & Margison, 2000;

Lysaker & Buck, 2010). While medication can reduce symptom severity it fails to ad-
dress other elements that are important in the recovery process such as ease and skill
in relating to others and understanding the meaning of ones experiences (Dickerson
& Lehman, 2011; Lysaker & Buck, 2010).
Metacognitive Narrative Psychotherapy for People with

Schizophrenia
One psychological approach with a growing evidence base is dialogically-informed,
metacognition-oriented individual psychotherapy (Bargenquast & Schweitzer, 2012;
Buck & Lysaker, 2009; Lysaker, Buck, & Ringer, 2007; Lysaker, Davis, et al., 2005;
Salvatore et al., 2009). Semerari is credited with being the first to suggest that metacog-
nition should be the target of interventions in people presenting with psychotic
symptoms (Semerari, 1999). The integrative metacognition-oriented approach has re-
cently been developed into a manual which draws on both narrative theory (Angus &
McLeod, 2004; Salvatore et al., 2012) and the seminal work of Lysaker and colleagues
(Lysaker, Buck et al., 2011). Manualised Metacognitive Narrative Psychotherapy aims
to enhance self-experience and recovery in people diagnosed with schizophrenia by
addressing deficits in metacognition and by facilitating the development of richer
and more coherent personal narratives (Bargenquast & Schweitzer, 2012). A recent
study based on the manualised version of Metacognitive Narrative Psychotherapy has
demonstrated both case study and group improvements in self-experience and sub-
jective recovery (Bargenquast & Schweitzer, 2013). This approach is influenced by a
view of recovery as comprising both objective and subjective components (Anthony,
1993; Corrigan & Ralph, 2005). The subjective component of recovery allows for the
possibility that a meaningful life can be lived, including the attainment of life goals,
despite experiencing clinical symptoms of mental illness (Corrigan & Ralph, 2005).
The Dialogical Self and Metacognition

Lysaker and colleagues were the first to draw a link between deficits in metacognition
and disturbed self-experience (Lysaker & Buck, 2009; Lysaker & Lysaker, 2011) and
between enhanced metacognitive capacity and higher self-perceived recovery (Kukla,
Lysaker, & Salyers, 2013) in people diagnosed with schizophrenia. In conceptualizing
the experience of people diagnosed with schizophrenia, Lysaker and colleagues draw
upon a dialogical conception of human functioning in which ones sense of self is
understood as arising from intra- and inter-personal dialogues between different parts
of ones mind, referred to as self-positions (Hermans & Dimaggio, 2004; Lysaker &
Lysaker, 2011). People diagnosed with schizophrenia are purported to experience an
impaired ability to engage in a fluid, reflexive and sustained dialogue between different
self-positions. Deficits in metacognition impact upon a persons capacity to reflect
meaningfully on the minds of self and other, and to make meaning of such reflections.
As such these deficits are thought to underlie the limited dialogical capacities of many
people diagnosed with schizophrenia and the resultant experience of self-disturbance
which is reflected in disrupted narratives (Lysaker & Lysaker, 2001, 2002, 2011).
2 Australian Journal of Rehabilitation Counselling
PSYCHOTHERAPY AND SCHIZOPHRENIA
Narrative Reflexivity
A metacognitive narrative therapeutic approach can be envisaged as a process of
conversing with facets of oneself and others in a way that allows for meaningful con-
nections to be made between both internal and interpersonal experiences (Vromans,
2007). This process is operationalised in the current study in terms of narrative reflex-
ivity. In the current paper the term narrative reflexivity will be used synonymously
with metacognition to refer to a synthetic meaning-making process.
The Narrative Processes Model of Psychotherapy

Narrative reflexivity has been operationalised in previous studies which have focused
on psychotherapy process using the framework of the Narrative Processes model.
Narrative reflexivity involves making meaning of mental states and experience by
processing mental states within the context of ones experience of oneself including
thoughts, emotions, beliefs, memories and desires (Adler, Skalina, & McAdams, 2008;
Vromans, 2007). According to the Narrative Processes model, successful therapy
has three goals: the remembrance and description of past and current events; an
exploration of perceptions, sensations, emotions and thoughts around the remembered
events; and the reflexive analysis of events which allow new understandings to emerge
about self and others (Angus et al., 1999). According to this model therapy is viewed
as consisting of conversations that shift between three domains: external, internal
and reflexive modes of language (Angus et al., 1999). All three narrative sequence
modes are regarded as essential components of successful therapy (Angus et al., 1999).
Angus and colleagues developed the Narrative Processes Coding System (NPCS) as
a method for systematically categorising all narratives in psychotherapy transcripts
as operating in one of these three modes, providing a measure of the proportion of
narrative sequence modes used across each transcript (Angus et al., 1999).
An association between enhanced therapeutic outcome and narrative reflexivity
has emerged from previous studies (Angus & Hardtke, 1994; Levitt & Angus, 1999;
Vromans, 2007). Several studies of psychotherapy process and outcome using the
NPCS have found that in successful client-therapist dyads there was an increase in
the proportion of reflexive sequences over time (Angus & Hardtke, 1994; Levitt &
Angus, 1999; Vromans, 2007). These findings suggest that enhanced reflexivity, as a
process of making meaning from experience, is associated with improved therapeutic
outcome.
While there is growing evidence for the effectiveness of Metacognitive Narra-
tive Psychotherapy, the mechanisms which underpin this approach are yet to be
explored (Bargenquast & Schweitzer, 2013). To address this gap, the current study
operationalises metacognition in terms of narrative reflexivity, and explores narrative
reflexivity as a potential mechanism of change.
Aim and Hypotheses

This study aimed to explore mechanisms of therapeutic change in psychotherapy with
people diagnosed with schizophrenia by examining the association between changes
in narrative reflexivity and subjective recovery. Improved narrative reflexivity was

expected to be associated with increased recovery over the course of psychotherapy.
Method
Design
This study was situated within a broader process-outcome trial of Metacognitive
Narrative Psychotherapy for people with schizophrenia (Bargenquast & Schweitzer,
2013). This exploratory study utilised an intensive, repeated measures, case study
design with data reported descriptively. This method is in accord with the descriptive
methodology used by Angus and Hardtke (1994) in their exploratory study of brief
dynamic therapy for non-psychotic patients using the NPCS.
Participants
Participants were clients and therapists who met the inclusion criteria for the study.
Clients were recruited through community agencies within the non-governmental
sector and therapists were completing postgraduate studies in clinical psychology at
Queensland University of Technology.
Clients. Clients were nine adults (8 male, 1 female) aged between 2565 years (M =
44, SD = 12.76). Inclusion criteria were a diagnosis of schizophrenia consistent with
DSM-IV criteria, medication not being altered for one month, no hospitalisations for
the one month preceding the study, and ability to provide informed consent. Exclusion
criteria were intellectual disability and high risk of suicide or harming others.
Therapists. Therapists were seven provisional psychologists in a postgraduate clinical
psychology program. Therapists were female, aged between 2529 years (M = 26.8
years, SD = 1.47 years), and had between 1.53 years of professional experience.
Therapists received training in Metacognitive Narrative Psychotherapy, over a period
of two days, to achieve fidelity. They attended fortnightly supervision with supervi-
sors who had experience in the Metacognitive Narrative approach (Bargenquast &
Schweitzer, 2012).
Materials
Treatment intervention. Therapist-client dyads engaged in 3850 sessions (M = 46,
SD = 4.5) of individual Metacognitive Narrative Psychotherapy over the course of 12
18 months (M = 13.8, SD = 2.1 months). Therefore, the time between measurement
points varied depending on the length of the therapy. Each therapy session was 2050
minutes in duration (M = 47.8, SD = 6.7 minutes). The therapy was based on a
manual (Bargenquast & Schweitzer, 2012) which draws upon the work of Lysaker and
colleagues (Lysaker, Buck et al., 2011).
Narrative Processes Coding System (NPCS). The NPCS provides a method for
systematically categorising all narratives in psychotherapy transcripts as operating
in one of three narrative process modes: external, internal and reflexive modes of
language (Angus, Levitt, & Hardtke, 1999). External narrative sequences involve
description of events; internal narrative sequences consist of description of emotions,
bodily feelings, and how one feels in relation to self or other; while reflexive narrative
sequences occur when the individual attempts to interpret or understand events or
subjective experiences as they relate to self, other, or events (Angus et al., 1999).
The NPCS was used to quantify the proportion of reflexive language used within each
therapy session.
When clients verbal expression was notably impacted by schizophrenia-related
symptoms resulting in narratives that could not be coded, the code other was
included. In the current study training of raters continued until adequate inter-rater
agreement was achieved. Adequate levels of inter-rater agreement were achieved
for topic segments (7088%) and for narrative sequence modes (8289%) and were
comparable to previous research (Angus et al., 1999).
Recovery Assessment Scale (RAS). The RAS was used to determine change in
recovery of clients by comparing scores at start-, mid-, and end-treatment. The RAS is
a 41-item, self-report questionnaire measuring various subjective elements of recovery
using a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree) (Corrigan,
Salzer, Ralph, Sangster, & Keck, 2004). Items include, I can handle what happens
in my life; I have goals in life that I want to reach and My symptoms interfere less
and less with my life. The maximum possible score on the RAS is 204 and higher
scores indicate a higher degree of recovery. Internal reliability for the RAS in the
current study was adequate (Cronbach range = 0.910.95) and comparable to that
found in previous research (McNaught, Caputi, Oades, & Deane, 2007).
Procedure
Following ethical approval from the University Ethics Committee (Approval no.
1000000584) and clients informed consent, all sessions were videotaped. For each of
the nine clients, three therapy sessions the second, middle and second last sessions
were transcribed and de-identified by replacing client names with pseudonyms. First
and last therapy sessions were excluded as they were not thought to be typical of the
therapy approach.
The RAS was administered at the start, middle and end of treatment, to all clients,
by a therapist who was blind to the NPCS results. The transcripts were then coded
using the NPCS. The NPCS coder was blind to the RAS scores. Each narrative
sequence mode was calculated as a proportion of total sequences, for each therapy
session. Inter-rater reliability for the NPCS was calculated for 10% of the transcripts.
Data Collection and Analysis

Data for narrative reflexivity were obtained by calculating the proportion of narrative
reflexive sequences in three therapy sessions (first, middle and last) for each client
relative to the remaining external and internal narrative sequences. Recovery data
were obtained by calculating the total score on the RAS scale for each client at the
start, middle and end of treatment. These scores have been published in a previous
study (Bargenquast & Schweitzer, 2013).
Descriptive data are presented using proportions for narrative reflexive sequences
and total score on the RAS for recovery. Data were analyzed by qualitatively
comparing the proportion of reflexive narrative sequences in the therapy dialogue
at the start, middle and end of treatment. To examine the relationship between nar-
rative reflexivity and recovery, recovery scores and proportion of reflexive narrative
sequences were compared over time.
TABLE 1
Changes in outcome measure scores for entire cohort from start- to
end-treatment.
Client RAS Scores (points) Reflexive Sequences (%)
William +33 +23.7

Orlando +32 7
Dominic +19 +3
Humphrey +16 +13.5
Clancy +11 +16
Derek +6 +4.7
Walden +3 +1.7
Raymond 1 +14.5
Morrison 10 5.5
Note. RAS = Recovery Assessment Scale.
Results
Narrative reflexivity, defined as the ability to make meaning of mental states and
experience by processing mental states within the context of ones experience of
oneself, was assessed at three time points the start, middle and end of therapy. The
majority of clients (n = 7) demonstrated an increase in narrative reflexivity from start-
to end-treatment (see Table 1). The majority of clients (n = 7) also demonstrated an
increase in recovery from start- to end-treatment (see Table 1). The recovery measure
comprised a total score which reflects a specific number of domains related to the
recovery process. These domains comprise the following: Personal confidence and
hope which reflects internal factors such as confidence and determination, willingness
to ask for help and reliance on others which both reflect external factors related to the
ability to seek support from others, goal and success orientation reflecting a persons
desire to succeed and perceived ability to attain goals and lack of domination by
symptoms which means that although psychiatric symptoms may still occur they are
not the focus of the persons life (Corrigan et al., 2004). For six clients an increase in
narrative reflexivity was associated with an increase in recovery (see Table 1).
The recovery data has been reported in a study which included the current cohort
and reported significantly increased RAS scores with a large effect size for the overall
sample, F(2, 20) = 6.75, p = .006 (Bargenquast & Schweitzer, 2013).
We present case vignettes for three of the nine cases, with the three cases being
representative of patterns of narrative reflexivity and recovery for the client group.
William: Increase in Recovery and Narrative Reflexivity

William was a 37-year-old male who had lived with a diagnosis of schizophrenia for
over 20 years. He participated in a total of 41 therapy sessions over a period of 12.3
months. William demonstrated a remarkable improvement in recovery which was
accompanied by an increase in narrative reflexivity (see Figure 1). William expressed
a wish to complete therapy early as he believed that the world was going to end around
FIGURE 1
William: Recovery scores and percentage of reflexive sequences in each transcript at start, mid-,
and end-treatment.
the time he was due to finish the therapy trial. Despite his desire to end therapy early,
William spoke very highly of the therapy, I think Ive definitely made progress over
the time weve been talking so I feel a lot better in myself too you know, I havent
had any delusional thoughts for a while or heard voices or anything like that. Most
of it was the medication but definitely the therapys been helping as well. In session
41, William recognised several specific gains he had made over the course of therapy
including learning to express and deal with his emotions, increasing his capacity to
have control over himself and his thoughts, and improving his ability to make sense
and hold a normal conversation with people.
Orlando: Increase in Recovery and Decreased Reflexivity

Orlando was a 36-year-old male who had lived with diagnosis of schizophrenia for
less than five years. Orlando was completing a bachelor degree. He participated in
a total of 50 therapy sessions over a period of 12.6 months. Orlando demonstrated
a progressive increase in recovery from start- to end- treatment and a small and
progressive decline in narrative reflexivity (see Figure 2). It was noted that Orlando
had difficulty connecting with his therapist and was often experienced by his therapist
as aloof and cold. During therapy sessions, he tended to narrate long and detailed
stories, in the external narrative mode, during which the therapist felt it was not
possible for her to interrupt or offer her own thoughts. The therapist who interviewed
Orlando, to obtain his recovery scores, observed that he tended to rely more on the
external narrative mode in response to anxiety or confrontation.
Morrison: Decrease in Recovery and Narrative Reflexivity

Morrison was a 57-year-old male who had lived with a diagnosis of schizophrenia
for over 20 years. He participated in a total of 43 therapy sessions over a period of
15.2 months. Morrison demonstrated a progressive decrease in recovery from start- to
end-treatment (Figure 3). Narrative reflexivity also decreased overall with an initial
FIGURE 2
Orlando: Recovery scores and percentage of reflexive sequences in each transcript at start, mid-,
and end-treatment.
FIGURE 3
Morrison: Recovery scores and percentage of reflexive sequences in each transcript at start, mid-,
and end-treatment.
increase from start- to mid-treatment followed by a decrease from mid- to start-

treatment (see Figure 3). Further, at end-treatment 4.5% of Morrisons therapy tran-
script was coded other compared with 0% at start- and mid-treatment.
Morrisons therapy was complicated by transference issues. He reportedly devel-
oped romantic feelings towards his therapist, which may have indicated an erotic
transference, as evidenced in an excerpt from session 22, Im angry at myself because
I have wanted you to be so much more that I know you could never be and thats
upsetting to me. He also was hospitalised towards the end of treatment due to a
psychotic episode, and experienced particular difficulty with termination.
Discussion
An overall increase in narrative reflexivity was associated with enhanced therapeutic
outcomes for the majority of clients. This finding provides preliminary support for
narrative reflexivity as a potential mechanism of therapeutic change underlying the
demonstrated effectiveness of Metacognitive Narrative Psychotherapy (Bargenquast
& Schweitzer, 2013). Although there was an overall association between narrative
reflexivity and recovery for six of the nine clients from start- to end-treatment, the two
measures did not always directly track one another. The results of a previous case study
(Lysaker et al., 2007) suggest that in some cases metacognitive ability may increase
before change is reflected on other outcome measures, which may partially explain the
lack of a direct association between narrative reflexivity and recovery in some cases.
The association reported between narrative reflexivity and recovery is theoreti-
cally consistent with the suggestion that deficits in metacognition may underlie the
social, vocational and personal difficulties that are commonly experienced by people
diagnosed with schizophrenia (Lysaker, Erickson et al., 2011). Deficits in metacogni-
tion have been linked with several barriers to recovery including a reduced ability to
solve problems, to engage in relationships with others, to regulate emotions and to
maintain a coherent sense of self (Lysaker et al., 2007). It is theorised that Metacog-
nitive Narrative Psychotherapy serves to facilitate enhanced recovery by providing a
space in which clients can practice metacognitive capacities (Lysaker & Buck, 2010).
It is expected that by practicing within the therapeutic relationship, clients will then
be able to apply their developing metacognitive skills, in their wider lives, leading to
improved quality of life (Lysaker & Buck, 2010).
Improvements in narrative reflexivity were not linear which is consistent with
previous studies of metacognition and narrative reflexivity (Buck & Lysaker, 2009;
Levitt & Angus, 1999). For the majority of clients an overall increase in narrative
reflexivity from start- to end-treatment involved an initial increase in narrative reflex-
ivity from start- to mid-treatment followed by a decrease towards termination. This
pattern points to potential negative effects of anticipating termination on therapeutic
gains. A good therapeutic alliance provides a safe space in which the therapist can
challenge the client to extend their skills into often difficult territory such as identify-
ing emotions or thinking about the possibility that ones thoughts are fallible (Lysaker
& Buck, 2010). Impending termination may reduce some clients perception of safety
within the therapeutic relationship, leading clients to rely more on the external nar-
rative mode to manage negative affect aroused in response to ending the therapeutic
relationship (Lysaker & Buck, 2010). Alternatively, the pattern of an increase in
narrative reflexivity followed by a decrease may be part of a larger pattern consistent
with findings from previous case studies where significant gains in metacognition were
often followed by losses (Lysaker et al., 2007; Lysaker, Davis et al., 2005).
While the majority of clients demonstrated increases in narrative reflexivity and
recovery, Orlando and Morrison deteriorated in one or both of these measures over
the course of therapy. Orlando gained benefit from the therapy sessions without a
related increase in narrative reflexivity. Morrison demonstrated a decrease in both
recovery and narrative reflexivity. The complexity of the trajectories suggests that
narrative reflexivity is unlikely to be the only mechanism of change underlying the
therapeutic approach.
Outcomes may be interpreted in the context of the experience of intersubjectivity

as threat in people diagnosed with schizophrenia (Lysaker, Johannesen, & Lysaker,
2005). This refers to the experience of interpersonal interactions as not only deeply
frightening but also as posing a threat to ones sense of self (Lysaker, Johannesen et al.,
2005). Successful interpersonal interactions require flexible movement between the
diverse self-positions that are evoked. As such, limited dialogical capacity is thought
to contribute to the experience of intersubjectivity as threatening and overwhelming
for many people diagnosed with schizophrenia. For example Orlando tended to relay
detailed stories in-session utilising the external narrative mode which left little space
for the mind of the therapist. This inhibited the possibility of genuine interpersonal
exchange where the therapist might have had the opportunity to offer interventions
aimed at enhancing narrative reflexivity. The romantic feelings that Morrison re-
portedly developed towards his therapist may indicate an erotic transference which
represents a particular form of intersubjective distress. Erotic transference can prevent
the deepening of the therapeutic relationship (Gabbard, 2005). While Metacognitive
Narrative Psychotherapy aims to facilitate dialogue between different self-positions,
potentially leading to an enriched experience of self and enhanced recovery, the
current findings suggest that special consideration needs to be paid to the individual
needs and capacities of the client and the therapeutic approach modified accordingly
(Bargenquast & Schweitzer, 2013). To better understand factors that influence client
deterioration during psychotherapy, more thorough investigation of clients that do
not achieve therapeutic gains is necessary.
Limitations
Analyses were descriptive and therefore no causal links can be drawn between narra-
tive reflexivity and recovery. It is possible that factors external to the Metacognitive
Narrative Psychotherapy intervention may have contributed to the observed changes
in narrative reflexivity and recovery. Recovery scores should be interpreted with cau-
tion as there are a range of variables that can impact scores including clients level of
insight. Over the long-term, an increase in self-awareness can be viewed as a positive
gain from therapy; however, over the short-term such insight may result in a decrease
in RAS scores.
The relatively small sample size limits the generalisability of the results, especially
given the heterogeneous nature of schizophrenia and the fact that the current sample
contained predominantly men. Future research, with larger and more variable sample
sizes is warranted. It would be of benefit to supplement case studies of client outcomes
with larger-scale empirical studies to assess change in narrative reflexivity and recovery
over time.
Conclusion
Metacognitive Narrative Psychotherapy is a new and innovative therapy for people
with schizophrenia, pioneered by Lysaker and colleagues (Lysaker & Buck, 2010).
The current research provides an exploration of the process of recovery for nine
people who participated in a manualised treatment program. Results suggest that
enhancement of narrative reflexivity may be a potential mechanism of therapeutic
change underpinning this treatment modality.
Findings have implications for research and clinical practice. At the research
level it will be important to extend the study by utilising larger sample sizes and a
variety of measures directly related to the theory which underpins the study. At the
clinical level, these findings lend support to the plasticity of functioning in clients
with a diagnosis of schizophrenia. Results also point to the importance of the therapist
creating an environment in which patients are able to reflect upon their experience
and, with the assistance of a skilled therapist, develop their capacity for meaning-
making and integration of experience across time. These findings are consistent with
the theoretical propositions advanced by Lysaker and colleagues (Lysaker & Lysaker,
2011) and provide preliminary support for the purported mechanisms underlying
Metacognitive Narrative Psychotherapy.
Future directions
Further research is needed to confirm the efficacy of Metacognitive Narrative Therapy
in the treatment of people with psychotic disorders. The next stage in the develop-
ment and evaluation of the model will require the implementation of one or more
randomised controlled trials, possibly comparing Metacognitive Narrative Therapy to
other psychological interventions that are gaining support. There are both mainstream
interventions, such as cognitive behaviour therapy for psychosis (CBTp; Wykes, Steel,
Everitt, & Tarrier, 2008), and some more innovative approaches such as the Open Di-
alogue (OD) approach (Seikkula, Alakare, & Aaltonen, 2011; Seikkula et al., 2003),
which have shown evidence for enhancing outcomes for people with schizophrenia.
Research with people in the earlier stages of the disorder is also warranted. While the
current study focused on people with long-term symptoms of psychosis, it is feasible
that the intervention described may be effective with persons earlier in their illness
trajectory and as such counteract progression to chronic disability, which is often
associated with schizophrenia. Finally, further analysis of therapy session transcripts
may aid the ongoing refinement of the approach, our understanding of what works for
whom, and improved assessment of patient appropriateness for treatment.
Acknowledgements
Thank you to Lyn Vromans for her invaluable assistance in understanding and applying
the Narrative Processes Coding System. Thank you also to James Banham for acting
as the independent NPCS rater.
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Mechanisms of Change in

Psychotherapy for People Diagnosed

N arrative reflexivity was investigated as a potential mechanism of thera-

Schizophrenia as a Disorder of Sense of Self

Australian Journal of Rehabilitation Counselling 1

in facilitating recovery from schizophrenia (Davenport, Hobson, & Margison, 2000;

Metacognitive Narrative Psychotherapy for People with

The Dialogical Self and Metacognition

2 Australian Journal of Rehabilitation Counselling

The Narrative Processes Model of Psychotherapy

Aim and Hypotheses

Australian Journal of Rehabilitation Counselling 3

in narrative reflexivity and subjective recovery. Improved narrative reflexivity was

4 Australian Journal of Rehabilitation Counselling

Data Collection and Analysis

Australian Journal of Rehabilitation Counselling 5

Client RAS Scores (points) Reflexive Sequences (%)

William +33 +23.7

Note. RAS = Recovery Assessment Scale.

William: Increase in Recovery and Narrative Reflexivity

6 Australian Journal of Rehabilitation Counselling

Orlando: Increase in Recovery and Decreased Reflexivity

Morrison: Decrease in Recovery and Narrative Reflexivity

Australian Journal of Rehabilitation Counselling 7

increase from start- to mid-treatment followed by a decrease from mid- to start-

8 Australian Journal of Rehabilitation Counselling

Australian Journal of Rehabilitation Counselling 9

Outcomes may be interpreted in the context of the experience of intersubjectivity

10 Australian Journal of Rehabilitation Counselling

Australian Journal of Rehabilitation Counselling 11

55(10), 12551270. doi: 10.1002/(SICI)1097-4679(199910)55:10<1255::AID-JCLP7>3.0.CO;

12 Australian Journal of Rehabilitation Counselling

Australian Journal of Rehabilitation Counselling 13

14 Australian Journal of Rehabilitation Counselling

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